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SKIN DISEAS 



'7 

DESCRIPTION, PAT 





* / 



DIAp;^IS; AND 
TREATMENT. 0^ 



BY 



TILBURY FOX, M.D., Lond, M.R.C.P. 

TKLUOir GW VMIYKBnTT COLLEOX, 
PHTROIAN iO THX 8XIH DKPABTlfKNT OF UnVEBKITT COLLEOB HOSPXTAI^ 



FIRST AMERICAN FROM LAST LONDON EDITION. 



KDITED BT 



M. H. HENRY, M.D., 



■UBOSOV TO TBK NKW TOBX SUBPSnUIlT— DXPABnaCNT OT VKNKBXAL AND SKIK DIBEAnm. 



rXLLOW OF THX VXW TOBX ACADXICT OF XEDICnvX. 



• •• 
• • • • 






• • 



• • 




/ 



NEW YORK : 
WILLIAM WOOD AND COMPANY, 

27 GREAT JONES STREET. 
1871. 



^ 






• • • 



• • 



• * • ••• 
« • • • 

• • •• • 

• • • • 



• • • 



• • 



• • • • • , 

• • •• •• 

•• • • • • • 



mi 



PREFACE TO THE AMERICAN EDITION. 



I HAVE, with the consent of the author — whose engagements 
would not permit him at this time to revise the last edition of his 
work — prepared the present volume for tlie American Student and 
Practitioner. 

The undeniable want of such a work in this country is, I think, 
BuflScient apology for offering this edition to the profession. 

I know of no work on Dermatology in our language that combines 
so completely the results of a thorough knowledge of the pathology 
of skin diseases, such sound clinical observation, and so rational a 
system in the application of therapeutics. 

The attractive manner in which the book is written will, I feel 
assured, be the means of conveying a better knowledge of a large 
class of interesting diseases which have not in this country, until 
recently, received the attention which their character and importance 
deserve. 

The book is a good one; so good that I have refrained from tres- 
passing on its pages or the patience of the reader with many " notes 
and additions." 

With the exception of a short account of a new disease (rhino- 
scleroma) described by Hebra, and a more systematic arrangement 
of the formulae, I have done little more than follow out the sugges- 
tions of the author contained in notes, and in the Appendix to the 

last English edition. 

M. H. H. 

IftT WiR Tanmr-roirfiTH Strekt. New YosXt 



PREFACE. 



Stimulated by the very favorable reception which tlie profession 
has accorded to my two previous works, — the one on the s])ecial sub- 
ject of " Vegetable Parasitic Diseases," and the other " Skin Dis- 
eases in General," and guided by the kindly suggestions of my 
critics, and by the experience gained in my special department for 
Skin Diseases at Charing Cross IIos))ital, I have attempted, I hope 
not unsuccessfully, to produce a book which I believe to have been 
really wanted — a book containing a concise and practical account of 
Diseases of the Skinybr general use. 

The present work may be regarded as a second and condensed 
edition of my two former works combined, re-written and re-cast, so 
as to suit both practitioners and students. In addition there is given 
the substance of a course of lectures recently delivered at Charing 
Cross Hospital. 

The various licensing bodies are wisely showing an increasing dis- 
position to demand from the student a definite knowledge of diseases 
of the skin. This is the case particularly with the University of 
London, and also, of late, with the College of Physicians, the Col- 
lego of Surgeons, &c. Keeping prominently in view the wants of 
the student in this respect, I have given a pretty full account of the 
elementary lesions, the description, the pathology, the diagnosis, and 
the principles of treatment of skin diseases. Moreover, I have 
incorporated with the Index a Glossary containing the derivation 
and meaning of terms, in the belief that it will be of much service 
to the reader. 

A large number of students enter the public services, and have to 
undergo special instruction preparatory to foreign service — at Netley 
for instance. I have therefore sought to aid them by including in 
the work an account of diseases affecting the skin which they will 

be caUed upon to treat in India, China, and other parts : ex. gr.. 



VI PREFACE. 

Delhi boil, Bisbra bouton, Framboesia, Leprosy, Buenemia tropica, 
Guinea- worm disease, the Madura foot (India), Ngerengere (New 
Zealand), Cochin-China ulcer. Some very interesting matter will 
be found in the Appendix relative to the so-called " Army Itch." 

It has seemed to me possible likewise to meet the requirements of 
the practitioner by amplifying the sections on diagnosis, and provid- 
ing a special Formulary, containing 200 selected prescriptions. At 
the end of the sections on treatment reference is made bv number to 
various formulae of use in particular diseases. The formulae are 
classified, and to each is appended the name of the disease in which 
it is useful. Whilst the student, therefore, may use the book as a 
whole, including the Glossary, the practitioner may, if he desire, 
merely refer to the sections on diagnosis and treatment, and to the 
Formulary, where I believe he will find what he requires. 

The classification of diseases is simplified, I hope; it is new, and 
in accordance with the plan proposed by the College of Physicians 
in its new nomenclature report, and with my own strong convictions. 

Tlie whole of the subject of Parasitic Diseases is fully illustrated 
by woodcuts ; and amongst others is a representation of the Madura 
foot, not figured as yet in any English work. In another part of the 
work is a representation of Delhi boil. 

My thanks are due to Mr. Erasmus Wilson, F.R.8., Dr. Lionel 
Beale, F.R.S., Dr. McCall Anderson, and Dr. Purser, for the use of 
illustrations; and to Dr. Lawson, C.B., Dr. Gordon, C.B., Mr. 
Perry, R.A., Dr. Marston, R.A., and others, for valuable information. 

43 SackvUle Street, Piocadflly, W., 
October 1, 1BB». 



CONTENTS. 



CHAPTEB PAQX 
.1. INTRODUCTION— IMPORTANCE OF STUDY OP SKIN DISEASES— A KNOWL- 
EDGE OF GENERAL DISEASES REQUIRED — WILLAN^S RESEARCHES. . 1 

n. GENERAL PATHOLOGY — ELEMENTARY LE8I0N& 5 

m. ETIOLOGY — BLOOD TISSUE AND NERVE CHANGES — INFLUENCE OF SEX, 
AGE, OCCUPATION, FLANNEL, SCRATCHING — CONDITIONS THAT DE- 
TERMINE THE LOCAL DEVELOPMENT OP DISEASE — COMPARATIVE 

FREQUENCY IN KIND OF SKIN DISEASE 14 

rV. CLASSIFICATION 21 

V. GENERAL DIAGNOSIS — PROGNOSIS— TREATMENT 25 

VI. ERUPTIONS OF ACUTE SPECIFIC DISEASES 32 

Vn. ERYTHEMATOUS DISEASES 44 

VUL CATARRHAL INFLAMMATION, OR ECZEMA 64 

IX. PLASTIC INFLAMMATION, OR LICHEN 79 

X. SUPPURATIVE INFLAMMATION, OR PUSTULAR DISEASES 91 

XL BULLOUS DISEASES 112 

XII. ALPHOUS DISEASE 123 

Xni. STRUMOUS DISEASES 130 

XIV. CANCEROUS DISEASES 136 

XV. SYPHILITIC ERUPTIONS 142 

XVL LEPROUS DISEASES 157 

XVII. HYPERTROPHIC AND ATROPHIC AFFECTIONS 166 

XVin. PARASITIC DISEASES 190 

XrX. NEUROSES OF THE SKIN 233 

XX. HEMORRHAGES 242 

XXI. CHROMATOGENOU8 DISEASES — PIGMENTARY 244 

XXn. DISORDERS OF THE GLANDS 248 

SUMMARY 264 

FORMULARY \ 269 

MINERAL WATERS IN SKIN DISEASES 295 

QLOaaARIAL INDEX 297 



CHAPTER I. 

IjrrRODUCTION — IMPORTANCE OF THE STt'DY OF SKIN DISEASES — A KNOWLEDGE 
OF GENERAL DISEASES REQUIRED — WILLAN's RESEARCHES. 

Diseases of the skin deserve to be more carefully studied than they are, 
for many reasons. They are excessively common, and amongst the first to 
test a man's self-dependence both in public and private practice amongst 
the poor, in workhouses and hospitals, as well as private patients. They 
are specially calculated to educate the faculty of minute observation. Their 
occurrence affords ample opportunity for gaining the confidence of patients, 
because these ailments are seen as well as felt ; their inveteracy and dis- 
figuring character often affect in a peculiar manner the personal comfort and 
vanity of men and women, so that relief is estimated at a comparatively 
high standard, whilst the good or bad effect of treatment, in the majority 
of cases, can be readily appreciated by the attacked. Many cutaneous mis- 
chiefs are contagious, and transmissible from one subject to another. It is 
highly important to be able to speak positively on this point in regard to 
individual cases. One of the commonest opinions demanded from a medical 
man concerns the necessity for isolating one or more members of a family, 
with the view of preventing the spread of skin diseases. An error of diag- 
nosis may allow the dissemination of ringworm throughout a school, bring 
discredit to the practitioner, and serious loss to the proprietors. This is 
but one of many examples that might be adduced to show that he who has 
a fair knowledge of diseases of the skin has an immense advantage in the 
practice of medicine. 

And there are other considerations. Foremost is this, that accurate ob- 
serration of the morbid changes that go on in the skin is destined to throw 
much light upon the pathology of internal organs. But the truth of the 
statement I started with must be self-evident. The successful study of skin 
disease necessitates a knowledge on the part of the student, whoever he may 
be, of diseases in general — and the only efficient treater of cutaneous ail- 
ments is he who is master of the details of general therapeutics. The same 
disease, as it occurs in persons of different diathetic tendencies, requires to 
be handled in a somewhat varying manner : eczema, for instance, in an old 
and gouty, a young and pallid, or a scrofulous subject, requires not the same, 
but a modified treatment. The rank specialist or mere empiric would diag- 
nose the eczema, pay no heed to the diathesis, and employ a therapeuto, 
which he has stereotyped, as suited to all cases, under all conditions. The 



2 INTRODUCTION. 

• 

philosophic practitioner, bringing into use his knowledge of medicine in 
general, would be careful to take advantage of known specifics ; but he would 
treat any constitutional condition which tended to prevent reparative action, 
and rectify errors of function or departures from healthy action in organs 
and parts which bear relation by interdependence of function, and so influ- 
ence the diseased skin. There is also, it must be remembered, a certain 
unity of character about diseased actions in various parts of the body, which 
justifies us in instituting a compaiison between the morbid processes in dif- 
ferent organs. A recognition of the changes in one, will not unfrequently 
throw light upon the nature of those occurring in another organ, about 
which, however, some doubt exists. There is also a more definite relation 
than this between the skin and internal organs. The ability to detect mis- 
chief of different kinds in the body in which a skin disease exists, often- 
times enables one not only to unravel more completely the nature of the 
latter, but to remove a cause of general debility, or one that checks elimi- 
nation, or that in other ways interferes with the due play of the via medica- 
trix naturce in the cure of skin disease. The removal of a stomach, a kiihiey, 
a uterine, a liver derangement, gives a patient a much bettor chance of get- 
ting well under treatment intended to cure a coexisting skin disease, and to 
effect this — i.e., to be a successful dermatologist— one must be a well-in- 
formed physician. One of the most impoi'tant i*elationships which should 
be considered is that of the skin and kidney functions. 

In no book, in no teaching, in no practice, is any prominence given quoad 
the ti*eatment of skin diseases, to the importance of our being guided by a 
consideration of that which the physiologist impresses ujKjn us with jieculiar 
emphasis — the relation which subsists between the functions of skin and 
kidney. The dermatologist pi*actically ignores the fact in the pathology to 
wliich he pins his faith and the therapeutics he adopts. On the face of it, 
this total abnegation of a great physiological fact can but be, as my ex|>erience 
teaches me, an egregious blunder : but cutaneous medicine is the slave of 
empiricism. The skin is often made to relieve kidney disease with the 
fullest success ; why, then, is the converse not more frequently and confi- 
dently effected ? 

Hemembering that the kidneys form the safety-valve by which a proper 
balance of fluid (and waste) is kept in the system (the amount secreted de- 
pending in some degree upon the state of the fluids, the cutaneous exhala- 
tion, etc.), and that there is not necessarily any relation between the quan- 
tity of urine and that of its solid contents — it may be affirmed that deficient 
action of the kidneys (as to solid and fluid) may (in old people es)»ecially) 
very materially aflect the occurrence of skin disease. Eczema may be taken 
as an example. Speaking generally, deficient kidney elimination may — (1) 
Determine the occurrence of diseaee. The skin will have more work to do 
where there is a sluggish action of the kidneys, and the blood circulating in 
and through it may consequently be charged with more nitrogenized matter 
than usual, especially in gouty and rheumatic subjects ; and if disease have 



INTRODUCTION. 3 

a tendency to show itself, its manifestation will be at once encouraged or 
excited. Therapeutics proves this indirectly in the familiar instance of the 
influence of colchicum and« diuretics in eczema, in such cases accelerating 
the cure in many instances ; whilst the presence of an excessive amount of 
urea in the urine in eczema supports the proposition laid down. (2) It 
intennfies the obstinacy of existing diseases. This follows from what has 
been said, and will be found to be clinically true. There are two classes of 
cases : in one, the total urea formed in the body is above the average, and 
in the other it may be normal ; in either case the deficient excretion (com- 
paratively speaking) produces to a certain extent a like result — the presence 
in the blood of an excess of effete products^ But deficient excretion may 
further be explained by the non-transformation into urea of the waste prod- 
ucts of the body by an arrest in the change of complex into simpler com- 
pounds. Dr. Fi-ank Smith's observations relative to indican in the uiino 
in eczema are conclusive on this point as to a deficiency of urinary excre- 
tion. It is our duty, then, when we know excretion is not active, to go 
further aTid find the cause of default. It may be an arrest in tbe normal 
metamorphoses, or a mere non-excretion of normal waste-products. The 
treatment is by diuretics in the one, by tonics chiefly in the other. It would 
seem sometimes as if the waste-products which should be excreted were de- 
rived from the changes going on in the skin itself, when that is extensively 
implicated in disease. (3) The deficient elimination of water by the kidney, 
leads, where gravitation comes into play, to the transudation of fluid in the 
su])erficial tissues, and occasionally to the production of blebs. 

The connection between chronic redness of the face and dyspepsia (particu- 
larly pyrosis), and between menstrual derangement and some forms of acne, 
is often marked, and may be cited as showing that our dermatology must be 
something more tban ** skin deep." It must comprehend the normal inter- 
relationship of the cutaneous envelope with internal organs, the deviations 
therefrom and their results, and the action of diathesis in modifying dis- 
ease. It must also be in a position to determine, when a given disease is only 
part of a general one, what the nature and history of that general disease is ; 
and it must include a knowledge of the pathology and therapeutics of chron- 
ic viflceral disease. The mode in which the latter acts will be noticed again. 
Enough has perhaps been said to indicate how varied and large an amount 
of knowledge the dermatologist should possess. 

I think it important to call attention to the fact that considerable differ- 
ences exist in the same diseases, according to the country and people amongst 
which they occur, and this is only what might be expected from the influ- 
ence of varying conditions of climate, diet, custom, etc Nothing shows 
this more conclusively than an examination of the writings and plates of 
foreign authors. Many of Hebra's descriptions (always good) of ordinary 
instances of disease really represent exaggerated forms of £nglish skin dis- 
ease—ex. gr., lichen ruber and scrofulosis, and even lupus. In the East^ — 
Syria and E^^t — syphilis is by no means so severe as in other parts of the 



4: INTRODUCTION. 

world. Pityriasis rubra and general psoriasis are not common with us, at 
least to such an extent as on the Continent. Again, fibroma molluscum 
and rupia are probably much milder in England than in Germany. I was 
very much struck with the difierence as regards scabies in passing through 
Hebra's wards ; it was altogether more ecthymatous ; and, indeed, the ulcer- 
ative aspect of most diseases in which ulceration is wont to occur, has 
seemed to me less marked in our own than in many other countries ; I speak 
not from theory, but actual observation. There is sui-ely a suflBcient reason, 
too, for the more sthenic character of diseases in England. A great truth 
underlies the contrast. I suppose that the meat-eating and porter-loving 
Englishman, with his hardy pursuits, acquires a gitjater amoimt of stamina^ 
and that degenei-ations dependent upon constitutional debility are not so 
marked in his case ais in that of the vegetable-feeding black or the fish-eating 
northerner. 

It would be out of place to pursue this topic further ; let me only add, 
then, that we must be careful not to trust absolutely to foreign description 
for learning to recognize, and certivinly in treating, English skin affections. 
I find that, on this point, I am in accord with American physicians. 

Before passing to the subject of Pathology, I would be allowed to make 
one refei-ence to Willan. It has become the fashion to depreciate his labors, 
and even to level a cei-tain amount of ridicule at the class to which I be- 
long — viz., that of the Willauites. We must i-emember that we cannot con- 
ceal, by a platitude of new ideas and liigh-sounding words, the fact that the 
essence of our present stock of knowledge, and the recent advances in cuta- 
neous pathology, have been mainly derived from the hai*d and solid work of 
Willan. He undertook the study and rearrangement of a class of diseases 
at a time when they were in the utmost confusion ; he brought to bear upon 
the question a large amount of very accurate observation, and was enabled 
to parcel out certivin " batches" of diseases, each presenting peculiar charac- 
ters, to establish a groupage which to this day represents the basis of the 
best classification for teaching purposes. And I am surprised at some of 
my dermatological confreres who depreciate the Willanean system as obso- 
lete and useless, and yet quietly incorporate it amongst the details of their 
own pet system of classification. Science is progressive, and Willan was 
not omniscient ; naturally, therefore, Willan's system of grouping skin dis- 
eases requires to be developed ; imfortunately there were no workers in the 
field inmciediatcly following Willan to carry on the work which he began ; 
but, modified in accordance with the pathology of the present day, Willan's 
arrangement constitutes the ti*ue plan u|)on which cutaneous diseases are to 
be arranged. The principle of the system is perfectly right, the details 
alone defective ; and it is an unfair tlung to make one flaw the evidence of 
the total worthlessness of the whole plan. Willan's labors, gauged by the 
medical circumstances of the time in which he lived, take the highest clini- 
cal rank ; they gave an impulse to the study of cutaneous diseases in Eng- 
land, and 8ecui*ed that country an enviable standing in regard to dermatolo- 
gy which it is to be hoped she will continue to holcL 



CHAPTER IT. 

GENERAL PATHOLOGY — ELEMENTARY LESIONS. 

There are certain types of morhicl changes occurring in the skin, such as 
" red blushes," " pimples," solid elevations, collections of serosity or pus, 
which are termed elementary lesions ; their desci-iption will form the subject 
of this chapter. 

Now, it is important at once to notice that a large number of cutaneous 
diseases are inflammatoiy in their nature. It is just as well, therefore, that 
we should start with some definite idea of what is meant by inflannnation. 

In the first place, the line of demarcation is by no means well drawn be- 
tween ordinary nutrition and inflammation. The latter may well be regard- 
ed in many cases as arising out of an exaggei*ated action of those processes 
that ai*e in operation in healthy nutrition. Infianmiation does not consist 
of a 8])ecial something introduced from without, but is simply an alteration, 
in one sense, of the relative activity of conditions that make up healthy 
nutrition ; and it would seem to be excited by disorder of the blood, of the 
nerves, and oven the tissues themselves. 

The first stage is active congestion ; this is followed by the escajMJ of 
fluid fi*om the vessels, which may bo plastic, forming more or less solid ele- 
vations (papulations) ; or serous, constitutmg vesiculation ; or the c^lfuscd 
fluid may become more or less purulent. The local disturbanc(j which is 
called inflammation may be induced by an infinity of causes; but con- 
gestion is the first stage in all cases ; consequently, although according to 
the nature and intensity of the cause, will the degi^ee of inflamniation 
vary — ^in some instances redness alone occurring, in othera papulation, vesi- 
culation, or pustulation, yet under all circumstances there will be a simi- 
larity in the aspect of corresponding stages of inflammation, as it occura in 
diflerent diseases. 

One of the prime objects of inflammation is the removal of effete and 
disorganized mattei^, and the repair of disordered tissue ; this will further 
explain why the process of inflammation under different circumstances 
should be similar. 

Some writers misinterpret this similarity. An attempt has been made to 
make aJl skin inflammations stages of the same disease. It is argued, for 
instance, that lichen, a pa]mlar, and eczema, a vesicular disease, are stages 
of one and the same affection, because, amongst other things, pai)\il(js are 
seen to become vesicles ; but this argument is initenablo until it be shown 
that the cause and character of the papule of an eczema is the same as that 
of a lichen. Thei*e is close resemblance, because thei*e is inflammation in 



6 ELEMENTARY LESIONS. 

both cases. The difference in the two instances must be found in the differ- 
ence of cause, in the character of the tissue action, and the inflammlitoiy 
products. The plastic lymph of lichen, the serosity and cell proliferation in 
eczema, conti-ast strongly — in both cases little elevations may occur, but in 
the one case they ai*e due to the presence of fibrillating l}T[n])h, in the other 
to serosity, and often abortive or undeveloped vesicles — though the two 
disr*ases to a gi-eat extent exhibit a close similarity in their development, 
there is a dissimilarity in the general nutrition — lichen is plastic, eczema, 
catarrhal inflammation. 

Given inflammation, the result will be modified according (amongst other 
things) to the blood state — ex., struma, syphilis, etc., the tissue action — ex., 
tendency to ])us formation, etc., or the influence exerted by nerve irritation 
in accelerating cell metamorphosis. These modifying conditions the phy- 
sician should stiive to understand. 

My object in making these renuirks is to point out that there must neces- 
sarily be a close similarity between the corresponding stages of inflammatory 
diseases, though the diseases, as a whole, may be really different ; and as I 
am 8|)eaking to the student, critics must not blame me for the absence of an 
elaborate essay on inflammation. 

With these introductory remarks I pass to the consideration of 

ELEMENTARY LESIONS. 

These are the ty])es of form assumed by morbid changes in the skin. 
They are generally arranged according to the plan originated by Willan. A 
correct undei-standing of their natui*e is essential to accurate diagnosis. The 
elementary lesions are as follows: maculie or stains, erythema, papules, 
squamft*, vesicles, blebs, pustules, and tubercula. Tliese are followed by 
certain other or secondary changes — viz., excoriation, crusts, scales (second- 
ar}'), cicatrices, staining, etc, 

I shall here give a general summary of these various conditions, leaving 
the minut^T details to be filled in in speaking of individual diseases. 

MncnUK are discolorations, mostly of primary occurrence, and often con- 
stitute the sole change in the skin. They are usually unaccompanied by 
hy))cra*mia. The term maculte is often limited to pigment alteration, the 
seat of which is the rete mucosum ; but we may here not^ that there ai*e five 
groups of discolorations or stains: (1) pigmentaiy ; (2) parasitic, as in 
chloasma ; (.')) syphilitic ; (4) hiemori'hagic, as in purpura ; and (5) chemi- 
cal, for instance, that induced by nitrate of silver, or by carbazotic acid. 
Now, the hftMuorrhagic and chemical grou))s are readily distinguished. Para- 
sitic and syphilitic stains are often confounded, esjK^cially in the case of 
chloasma : this is fully noticed in the pro])er place. The ]>igmentai7 stains 
are those of most consetpience here. They may be arranged thiut, in three 
sulnlivisions : — 

A. Idiopathic. Tliese are generally excited by external irntants, and are 
(I) traunuitiCy including stains induced by pressui*e in handicrafts, 



ELEMENTARY LE8IOK8* 7 

and by the clothing, those following as the result of congestion in 
many local diseases, as eczema of the leg ; (2) toxic, including the 
stains which follow the application of heat, the action of the sun, 
mustard poultices, and the like. 

B. Symptomatic stains, or those wliich follow as a consequence of disease 

or change at a distance, including the pigment deposits which occur 
in connection with some natural physiological change in the body, as 
in pregnancy ; those which occur in connection with uterine disorder, 
in cachexias, cancer, amemia, liver or supiu-renal disease, or nerve 
disorder, as in leprosy. 

C. Congenitfd, including pigmentary moles and nssvi. 

This table should be referred to in reading the chapter on chromatogenous 
diseases. 

EryOiema, or CapiUary Congestion, or simply Jlas?^. — Erythema is due 
to impeded circulation, and in it the capillary layer of the skin is involved. 
There are two chief foims of erythema or congestion, — A, active, B, passive. 
The latter gi*oup may be dismissed with a few words. The color of the 
erythema is dull, bluish, the suiiace is cold. It is generally of mechanical 
origin, and produced by venous obstruction. It may be symptomatic of a 
more general disorder — for instance, a weak heart. The great majority of 
cases are active forms of erythema. Here the color is more or less of a 
bright hue, and accompanied by heat, swelling, and pain — ^in fact, the ordi- 
nary signs of inflammation. The erythemata of this nature may l>e ranked 
under three heads : . (1.) Those forms which constitute the sole disease, as 
in local hyperiemia, produced by local causes — ex., irritants of all kinds, 
and heat. (2.) Those which form the main feature in general disorders, 
and are so important as really to constitute the disease that requires treat- 
ment — ex., the ordinary febrile erythemata ; in this case the rash is more 
or less partial. (3.) Those which constitute a prominent feature in more 
serious and fatal affections — ex., measles, scailatina, the acute specific dis- 
eases ; here the rash is general over the skin. 

We might make only two groups of erythemata, local and general, the 
latter including groups 2 and 3 in the above aiTangement. In these erythe« 
mata there is (1) redness which varies according to the part of the capillary 
plexus involved, being punctate when the follicular plexuses are specially 
concerned, uniform if it be the hoiizontal vascular surface of the derma, 
diffused and general if the blood be disordered as a whole, or circular if the 
vessels under the governance of one or more nerve twigs are alone the seat 
of disturbance — the color vaiies according to the activity of the circulation 
and the state of the general health ; (2) swelling : this is due to the gi*eater 
volume of blood present and the escape of fluid from the vessels into the 
tissues; (3) a rise in tem])erature; (4) disordered sensation, pain, or tin- 
gling, or burning; (5) an acute course usually; (6) secondai-y effects, such 
desquamation, exudation, hypertrophy. 



8 ELEMENTARY LESIONS. 

Wlien the deeper tissues — the connective — in addition to the skin are 
affected, we have what is called phlegmonous inflammation. 

The points of importance are the hue of the redness, as indicative of 
venous or arterial stasis, and the extent of the redness as significant of a 
general or a local disorder. 

JPa2mle8, or " pimples," are differently explained by different dermatologists. 
They are little solid elevations of the skin, and are produced by a variety 
of causes, as follows — (1) Deposition in the skin of plastic lymph ; (2) the 
turgescence and consequent erection or prominence of the follicles (the 
perspiratory, the sebaceous, or the hair) ; (3) by collections of epithelium 
or other substances in these follicles, and the projection of these masses; 
(4) by enlargement of the papillaj ; (5) and (6) by hypertrophous growths 
of the derma, as in small warts. Tlie tnw papule, that which occurs in 
lichen, is due to the effusion into the skin, especially the papillary layer of 
plastic lymph (plastic inflammation). The papules are palish or white, 
flesh-colored or dull red, with no appreciable surrounding congestion as a 
rule, lasting a variable time, and disappearing by resorption and slight des- 
quamation. On close inspection the papules are seen to be sometimes 
transparent at the point, from tlie presence of lymph, which may as yet not 
have thoroughly fibrillated (solidified), hence on scratching the point of the 
papule off a little oozing may take place. The lymph comes from the fol- 
licular plexus as well as the vascular loops in the papillao, and therefore the 
papule sometimes looks as if it were a turgescent follicle, but the true papule 
is essentially non- vascular, pale, and solid. An inflamed follicle is ** follicu- 
litis," not a papule, which as I stated Ls really a solid lymph formation. 

Tliere are certain varieties of papules. Tliey are small and hard on the 
outer surfaces of the body, larger and softer on the inner surfaces, about the 
neck and the face. They are absent from the palms of the hands and the 
soles of the feet. They are large in syphilis, large and flat in lichen ruber. 
Tliey may be scattered, or in groups forming patches, which increase by the 
development of papules at the circumference. In some cases, the character 
of the nutrition is such, that scratching is followed by hcemorrhage, instead 
of lymph effusion, as in pi-urigo, and here at the apex of each papule is 
seen a black speck, produced by dried blood. Papular disease (and I am 
speaking of papules that are produced by a deposit of lymph in the skin) 
is chronic ; it is accompanied by a tendency to, or actual thickening of the 
skin, and moi-e or less itching. It is fibrous or plastic inflaimnation. 
Secondary papules are produced as the result of chronic ii-ritation, and they 
may be either lymph formation or congested follicles. 

Large and flat papular elevations occur in pniiigo, and are produced by 
enlargement of the little aix^s of the skin enclosed by the natural furrows. 

Vesicles, — As in the case of the ]wpule, properly so called, we have the up- 
raising of the skin by plastic lymph, so may an elevation result from the 
effusion of fluid which does not tibrillate, but which raises the skin above it 
into a minute bladder, and then makes its exit through the cuticle, foi*ming 



ELEMENTARY LESIONS. \f 

" discharge." The little bladdery elevation so produced is called a vesicle. 
The fluid comes from the capillary plexus of the skin. Some dermatologists 
think that a vesicle is a modified papule, but it seems to me that in the two 
cases there is a marked difference in the general nutrition — the one produc- 
ing plastic, the other serous material — the one leading to a ** dry," the other 
to a ** moist " disease. Vesicles are of small size ; they may be isolated 
(scabies), discrete as it is called, or they may run together, as in eczema, their 
walls rupturing, and a weeping surface being produced. When the cuticle 
is thick, the fluid does not escape readily, the vesicle may then enlarge by 
augmentation of fluid, or by junction with others, and so what are called 
blebs or bladders are produced ; this is common about the fingers. When 
the fluid does escape, it dries into crusts ; the discharge is often excessive ; 
vesiculation may leave behind a dry, red, fissured surface. The essence of 
vesicular disease, however, is the free outpouring of fluid which is more or 
less serous, and tends to elevate the skin into what are called vesicles : it is 
identical with catarrhal inflammation in other parts. The contents of vesicles 
are hsematoid, pyoid, granular and mucous corpuscles, plastic lymph, fatty 
matter, and amosbiform cells. The reaction may be acid, neutral, or alkaline. 
The fluid is at first transparent, but soon becomes quickly opaque or puri- 
form in those instances where there is a " pyogenic (pus-producing) habit 
of body " present. 

An elevation of the cuticle by fluid may occur in consequence of the 
non-escape of the sweat when this Ls over-abundant, and this is the nature 
of sudamina and miliaria, but in such cases the source of the fluid is 
obvious* 

^leba* are simply large vesicles ; their size is arbitrary, varying from that 

♦ The following note on the mode of formation of a bulla or blister, will bo 
read with interest and profit: — 

" As generally understood, a blister is supposed to be an exudation of fluid, 
which, discharged from dilated vessels, passes through the rete mucosum or 
Malpighian layer of the skin, and accumulates between the epidermis, that 
constitutes the elevation, and the rete mucosum, which is held to remain attached 
to the surface of the dermis. The difficulty which at once suggests itself here is, 
why there should be a detachment of the epidermis from the rete mucosum — why 
the papillae should not be led bare when the raised skin is removed. Some 
recent investigations by Professor Biesiadecki show that our previous knowledge 
of the process, though in the main correct, has not been complete or accurate. He 
has endeavored to fill up this hiatus, and has taken as the subject of his observa- 
tions the small vesications that are caused by a burn, because these are quickly 
produced, and are not, as in the case of the minute blisters which occur in disease, 
accompanied by any previously diseased conditions of the skin. If a subject be 
burnt with a hot iron, there will be found in the neighborhood of the eschar, after 
the lapse of a few hours, sundry small vesications ; these are well adapted for 
investigation. If such a blister be cut out with a portion of the adjoining skin, 
macerated in chromic acid, and imbedded in gum, complete vertical sections may 
be obtained. It is then found that both the papillae and the stratum Malpighii have 



10 ELEMENTABY LESIONS. 

of a j)ea to that qf a shilling, usually reaching the latter from the formed 
in a few hours : they are seated upon an erythematous base, are generally 
associated with ill-health, and come on without premonition. In consequence 
of their rapid formation and tke resistance offered by the cuticle, the bleb 
is tense and full, but absorption soon produces more or less flaccidity, the 
contents become opaque, sometimes sanious and bloody (rupia), and being 
discharged dry into crusts of yellowish or blackish hue, but sometimes of a 
raised conical form (rupia) ; beneath the crusts the surface is I'aw, red, and 
more or less dirty. Sometimes at the bottom of a bleb is found a disc of 
plastic matter, and the mw surface may take on a morbid action and secrete 
a thick tenacious fluid and even pus. Bullae are solitary or multiple, eon- 
fluent or isolated ; often periodic in old people. Blebs may be formed by 
the coalescence of vesicles, as in eczema of the fingers ; but these are linear 
elevations rather than circular cuticular elevations. In erysipelas, blebs 
are common. About the hands and feet of infants they are sometimes as 
syphilitic. 

The exact manner in which blebs are produced is a matter of doubt. 
Through the influence of nerves a sudden dilatation of the vessels may 

undergone important changes. In the smaller vesicles the papillae are enlarged, 
their connecting tissue presents lacunae, and the vascular loops are greatly dilated 
and apparently elongated. The epidermis is altogetlier detached from the papillae 
except in the hollows between the papillce, and the space between the two is 
occupied by innumerable very Que fibres, which seem to be on the stretch. The 
fibres do not at first sight give the idea of elongated colls, as they are of equal 
thickness and have no nuclei, though one or two may be scattered here and there. 
They readily stain with carmine. When the vesications are larger, and 
the fluid more abundant, the fibres are torn through, part adhering to the 
inner surface of the epidermis, part to the outer surface of the papillae. 
Amongst them, some club-like cellular structures, with nuclei in their interior, 
may be seen adhering to the papillae by their elongated extremities. In the 
serous contents of the vesicles a few round nuclei are suspended. Biesiadecki 
states he was long in doubt respecting the origin of these fine fibres, but he has 
now convinced himself that they really proceed from the cells of the rete mucosum, 
as the intermediate forms between the finest fibres and the unchanged cells may 
with care be seen, whilst the surface of ihe papillae is well defined, so that they 
could not proceed from the connective tissue. We may therefore conclude that 
in the formation of a blister from a burn there is, in the first place, a great dilata- 
tion of the blood-vessels, which immediately occasions a serous exudation. This 
permeates the tissue of the cutis and reaches the rete mucosum, the cells of which 
do not appear to be capable of imbibing fluid. As the deeper ones adhere strongly 
to the papillae, and as the accumulating serous fluid cannot escape through the 
condensed cellular layers of the epidermis, the cells constituting the rete mucosum 
are gradually put upon the stretch, at first being merely elongated, and finally 
becoming converted into fibres in which no trace of a nucleus can be discrerned. 
These facts appear to us to be of great interest, and they teach that vesicles may 
be traversed by a framework of fine fibres, as it is well known is the case with 
pustules — e. g.j those of small-pox." — Lancet^ Oct 10, 1868. 



ELEMENTABT LE8ION8. 11 

occur, and fluid rapidly escape ; and bullie occur specially in herpes and 
pemphigus, in the production of which diseases the nervous system is 
allowed to be greatly concerned. 

Pustules are elevations of the upper part of the derma, produced by pus, 
quickly formed, and coming rapidly to the surface. They are, on the whole, 
accompanied by more inflammation than are vesicles or papules, and by a 
dee(>er aflection of the tissues. Now, pustules have been divided into pii- 
mary and secondary. In the former we have hy]>er8emia, and the direct 
formation of pus quickly and at once, as in. ecthyma ; in the latter, the con- 
tents -of the pustule are rather puriform than purulent. The pustules com- 
mence as vesicles, the contents of which are transparent and serous ; by- 
and-by pus is therewith inteimingled. This is the case in scabies, and 
even variola and vaccinia, and in eczema impetiginodes. It is customary 
to make three kinds of pustules: — (1), psydracious, viz., those which are 
hard and pointed, which have a slightly red circumference, and are often 
seated at the hair follicles ; (2), phlyzacious, which are large, raised, vivid 
red, have an indurated base, and are replaced by thick dark scales; 
and (3), achores, a term applied to the small acuminated pustules that 
occur in the scalp : these are inflamed sebaceous glands (or boils). Boils, 
or furunculi, are regarded as pustules ; tliey are accompanied by swelling, 
heat, tension, and the formation of ^^ a core.'' This core is thought to be 
produced by circumscribed sloughing, or by strangulation of the tissues, 
caused by the swelling, or by a special exudation into the skin. Others 
aflirm by an inflamed and suppurating sebaceous gland, and I i*efer for 
further particulars to the description of furunculi, in the bo<ly of the work. 

Sqvumfe, or, simply, scales (I don't mean crusts which are the result of 
the drying of secretions) are of two kinds, epithelial and fatty ; the latter 
occur in affections of the skin, which are described under the head of " seba- 
ceous diseases ;" the former, epithelial, are found under many different con- 
ditions. In acute specific diseases, measles, and scarlatina, for instance, 
the cuticle may, so to speak, die, and then its scales are shed in wliat is 
termed " desquamation," or " peeling " of the surface ; a scaliness results 
from the disordered nutrition wluch follows the application of local irritants, 
or the growth of vegetable parasites ; and in most inflammatory affections, 
such as eczema, erythema, lichen, the epithelial formation is seriously inter- 
fered with, and scales are freely produced. In all these instances the 
scaliness is secondary to and occurs after the i*eal disease has fully shown 
itself. It is often mixed with more or less exudation. In another class, 
however, the excessive formation of epithelial scales is the essential and 
prominent change in the skin ; here the scales are primary products. 

We may therefore divide scales into pritnary and secondary^ and into 
epithelial or fatty, 1. In the epithelial vaiiety we have simply altered 
epithelial cells, produced by augmented formation or hypertrophic growth. 
They are thin, fine, branny, opalescent ; or thick, hard, dry, whitish, more 
or less opaque, rarely of a dark aspect, collected together in an imbricated 



12 ELEMENTARY LESIONS. 

manner (lepra vulgaris), with a more or less hjrpertropliied state of the pa- 
pillary layer of the derma ; or thrown off as soon as produced (pityriasis), 
or with only slight aggi-egation, perhaps forming a thin layer. The scales 
are produced in great abundance and with rapidity, but, histologically 
speaking, are not so perfectly formed as in the normal condition. In some 
cases they become granular, even fatty, or invaded by fungi, as in chloasma 
and ringworms. The over-formation of scales is generally accompanied by 
itching, slight redness beneath the scales, and in old-standing cases by crack- 
ing and Assuring of the diseased part, as in lepra vulgaris, producing a dull 
white, and compact cracked dry surface. When the scales are fine and 
branny, and constantly shed, what is termed furfuraceoua desquamation is 
present. Sometimes this scaliness may be associated with general inaction, 
and more or less atrophy of the skin ; and in that case the disease is xero- 
derma, or dry skin ; in an exaggerated degree, where the scales form plates, 
ichthyosis. 2. In the fatty variety there are epithelial scales, but they are 
loaded and surrounded by fatty matter from the 8eba<%ous glands. These 
fatty scales are rather plates that are ** stuck " on to the part, and can be 
more or less dissolved up with ether ; they are common in ichthyosis and 
seborrhcea. 

Sometimes large plates form, as in pemphigus foliaceus, for instance ; at 
other times the whole epidermis of the hand or foot may peel off in large 
masses, like parchment. 

Tuhercula, — This word, which sounds so like tubercle, is a very bad one. 
It Ls, however, so commonly in use that I am bound to define it, and to de- 
scribe what it includes according to general agreement. Willan meant it 
to signify any tumor of smallish size, not defined by the word papide. 
Here is his description : " A hard, small, circumscribed, and permanent 
•tumor, su])purating partially." Hardy defines tubercula somewhat as fol- 
lows : Little globular tumors, fii*m or soft, containing no fluid, formed 
deeply in the substance of the skin, at times disappearing by an insensible 
absorption, at others ulcerating, with prior softening, accomi)anied by loss 
of substance more or less deep and extensive. Tubercula, which might be 
replaced by the term degenerations, includes elephantiasis, keloid, framlxE- 
sia, cancer, lupus, epithelioma, rodent ulcer, the four latter commencing as 
hai'd nodules on the derma proper, and having as their especial features, 
the tendency to enlarge, spread, and ulcerate, with decline of the general 
health. The tubercules formed by degenerations are solitary (cancer) or 
multiple (framlxesia), at first often subcutaneous, the skin being apparently 
natural but soon becoming irritated, interfered with as to nutrition, hence, 
swollen, congested, softened, and at length ulcerated, when, in the majority 
of cases, out sprouts the diseased mass beneath. Tliis occurs in elephantia- 
sis, frambcesia, cancer, epithelioma, iif lupus, rarely in keloid. The surface 
then presents a variable asjKHJt ; it may be clean, or foul and exuding a 
dirty fluid (cancer), or scabbed in various degi-ee (lupus). The loss of sub- 
stance increases either superficially or deeply ; one part may heal whilst the 



ELEMENTARY LESIONS. 13 

other ulcerates, as in the varieties of lupus. The edge may be undermined 
and everted (cancer), or inverted, thickened, rdunded off, as in lupus ; and 
there may be more or less infiltration of the textures beyond the boundaiy- 
line of the sore (as in c&ncer), or congestion and oedema (lupus). 

Degenerations are chronic in character, often hereditary ; but I had better 
reserve further particulars. 

Such, then, are elementary lesions. I have incidentally noticed '' second- 
ary changes," but must add one or two additional particulars, (a) As re- 
gards desquamation^ this may result from hypei'semia whenever marked. It 
should be mentioned that in pityriasis rubra and pemphigus foliaceus the 
squamation is general. (6) As to crusting, this occurs in all discharging 
diseases. Crusts vary in appeai*ance with the nature of the secretion, ac- 
cording as this is serous, purulent, or bloody. If serous discharge exists, 
the crusts are thinnish and brownish ; if pus exists, they are thickish, light 
yellow, and more or less greenish, as in impetigo and eczema. Ci*usts are 
dark and adherent in syphilis, and cockle-shaped in rupia. They may be 
formed solely of fungus as in favus ; then they are dry, powdery, friable. 
Where discharge is slight and purulent, the crusts are adherent, hard, and 
dark, as in lupus. Where there is hair, crusting is of course favored, and the 
hairs help to prevent the falling of scales, (c) Cicatrices follow especially 
ecthyma, variola, hei*pes zoster, furuncle, anthrax, pustula maligna, syphi- 
litic acne, {d) Distinct ulceration is seen mainly in strimious inflammation, 
lupus, cancer, syphilis, elephantiasis. Loss of substance without ulceration 
by interstitial absorption in tubercular syphilis, eiythematous lupus, mor- 
phoBa, atrophia cutis, leprosy, the distention of skin in pregnancy, (e) Cysts 
are formed mostly by the blockage of the follicles and distention of the 
gland apparatus of the skin, the sebaceous and sweat glands, (f) Conden- 
sation of tissue which may be newly formed is seen in pityriasis rubra, 
keloid, morphoea, and scleroderma. Other details will be found (in regard, 
for instance, to the characters of different ulcei*s) under the head of Diag- 
nosis and in the descriptions of individual diseases. 



CHAPTER III. 

ETIOLOGY— CAUSES OP BLOOD, TISSUE, AND NERVE CHANGE — INFLUENCE OP 
AGE, SEX, FLANNEL, SCRATCHING, ETC. — CONDITIONS WHICH DETERMINE THE 
LOCAL DEVELOPMENT OP DISEASE— COMPARATIVE FREQUENCY IN KIND OF 
SKIN DISEASE. 

Now, in the last chapter the general appearances of diseased changes in 
the skin were discussed. It is now necessary to indicate more distinctly 
the causes of these changes. 

To comprehend rightly the natnre of morbid process in the skin, it 
is necessary, of course, that the student possess a correct knowledge of the 
healthy structure and healthy action of the skin. This I suppose him to 
possess. He must make it the standard of comparison, of course, in all 
cases. Now, in order that nutrition may be healthily carried on in any part, 
there must be — (1) a proper state of the blood ; (2) a proper condition and 
behavior of the tissues to be nourished; and (3) a right exercise of the 
controlling influence exerted by the nerves. And tiiese three must work 
harmoniously together. Deviations from health may originate consequently 
from a flaw in any one of the three conditions above named. The theoret- 
ical origin, therefore, of diseased changes in the skin may be specially in the 
blood, as we see in zymotic aflections ; in the tissues themselves, as seen in 
the case of wai'ts, cancer, keloid, lepra, etc. ; or in the nerves, as in prurigo 
and pruritus, and, it is thought and now generally taught, herpes. If the 
exact origin of disease be not as stated, the parts of the system chiefly con- 
cerned in the production of diseased conditions may be emphatically in one 
case the blood, in a second the tissues, and in a third the nerves. But of 
course, inasmuch as the ordinary action of these three agencies is bound up 
and related in the closest manner in health, in disease the misbehavior of 
one affects secondarily the proi)er action of the other of the three agencies 
concerned in healthy nutrition. So that all are more or less involved in 
disease when fully developed. 

Now, we are ready enough to ascribe disease to changes in the blood, but 
we do not s\ifficiently recognize the influence of perversions in the inherent 
cell life of the skin structures, nor the controlling supervision of the nerves 
in the generation of cutaneous disease. If we want an example of disor- 
dered tLssue-life, we sliall find it in cancer ; the local tissue changes are not 
sufliciently explained by any alteration in the blood current, there is no 
appreciable disorder of it, that is secondary to the cell proliferation, which 
is the essential disease in the early stage. Take keloid again — hyi>ertro- 
phous growth of the fibro-cellular tissue of the skin, is the only thing to be 



ETIOLOOY. 15 

detected ; it is apparently primary. These are examples of deviations from 
the normal cell-life of the skin, at present explained by no blood cause ; by 
nothing save a change originating in the tissues. 

Dr. A. Biesiadecki * has lately published some interesting observations 
bearing upon this point. He finds that there exist in the normal lamina 
mucosa, cells which differ entirely from the proper epithelial cells, and 
resemble connective-tissue corpuscles. 

In pathological conditions these increase in numbers and play an import- 
ant pai*t. This has been studied by Biesiadecki in condyloma, in eczema, 
and in pustular diseases. 

The commencement of vesiculation, for instance, in eczema, consists, 
according to our author, in the migration from the papillaiy layer towards 
the surface of numerous spindle-shaped cells, which at fii-st are seen to lie 
partly in the papillary layer, partly among the dee[)est layers of the mucous 
layer (that is, in the Malpighian layer). This migration gives rise to the 
softening and disintegration of the Malpighian layer and epidermis. 

Dr. Biesiadecki gives very excellent drawings of sections of diseased skin 
in which these changes are shown. I have seen the same amoeboid cells in 
moUuscum, and Dr. Sanderson informs me that he has met with them in 
pemphigus. It may be argued that in all these cases the changes in the 
tissues are due really to a primary alteration and the existence of certain 
pabula in the blood ; but making due allowance for this, it would still seem 
as if the tissues themselves originated some morbid processes, or at any rate 
directed the coiu-se of the final result. 

So is it in some degree with the nerves. It is probable that the origin 
of some diseases of the skin may really be in the central nervous system, 
or in the nerves themselves that run to the affected part, at any rate the 
nerves are mainly concerned, or they constitute the agency by which the 
morbid changes in the skin are produced. No one doubts that herpes 
results from irritation of the nerves related to the seat of eruption. It is 
true that the nerve disorder, which seems to be primary, may result from a 
blood change, but we know that it may also arise from a local impression, 
and each day pathology is more fully proving the neurotic origin of certain 
cutaneous diseases. 

Hitherto it has been supposed that the influence locally of the nervous 
system was mainly concerned in alteiing the calibre of vessels (contraction 
being under the guidance of the sympathetic and active dilatation, the 
cerebro-spinal nerves), but recent observations by Eckhard, Pfliiger, and 
Heidenhainiy have conclusively shown that it does more, especially in the 
case of glands. Pfiuger states that nerve twigs run directly into the cells 
of the salivary gland, and connect themselves with nuclei; and Heiden- 
baim, as the result of his researches, believes that nerve irritation, under 

• ** Beitrage zur Physiol, imd PathoL Anat der Haut,'' Sitzungsberichte der Wiener 
Akad., voL Ivi. p. 225. 



10 ETIOLOGY. 

certain conditionH, may induce lively cell formation and metamorphosis. 
ThoiHj aro tlieu three main ways in which the nervous system may act upon 
the skin (in addition to altering its sensibility, and through reflex action), 
lirHt, by inducing changes in the calibre of the vessels, and so influencing 
the trauHudation of fluid ; secondly, it would seem by encouraging an hy- 
l)c»rHctivity in the cell-life; and thirdly, where there is genei*al debility 
thi'ro is h'HHonod nervous control over tissue, the reparative process is not so 
aotiv(>, and the skin cannot resist so well as it should external influences 
that tund to injure it, or induce disease. 

1 have thuH far gonoralized so as to enable the student to comprehend in 
Honu^ dogi*eo the general sources and nature of the changes that occur in skin 
dlHiMiHCK, and to show that in different morbid process, disorder of the blood 
in onc», of the tissue-lifo in another, and of the nei*ves in another, areprinci' 
^HiUy conc«»rniHl \x& causes of mischief. 

jhit it would seem that not only are blood-tissue and nerve collectively 
and indivitlually involved in the pi\>duction of pathological results as regards 
the skin, but also the lymphatic system, which, however, one would imagine, 
fnuu the little notiiH? taken of it by the physician, is a thing out of place and of 
no H«»rvioo. My ivasons for thinking that changes in the fibi^o-cellular tissue 
and disonlor of tht» lymphatics are related, will be stated under the head of 
hy port rophies and atro))hies, in speaking of keloid, sclerederma, and their allies. 
Having thus stated the three main channels thi*ough which " causes " work, 
1 mwv now giv«> a sununarv of the more gi»nerally recognized influences that 
induiv blood, nerve, ami tissue ohangi*, and I especially enumerate the causes 
tltat pi\^duet^ 

A, Ai.TKUKi) Statks ok thk Hlooim iRRKXT. Thcv are — 

I. Acute s|HH»itlo diseases (virus action), small-|K»x, scarlatina, ru- 

Undrt, eto. 
:}. Tlu» oireulatiiui of 8|H»oial iH>i8*ui8, be they animal, ex., syphilitic: 
nuHlioinal Hulkstaui't's, <•.»/., ai'stMiio, Wlhulonna, coi>aiba, nitrate 
of siher (mv Krythemata) : or dietetic, such as shell-fish, giving 
riso to urti^niria, ixunvla, ervthenm, 
♦I, HonHhtary iliathesis, as in iohthyv^sds, psoriasis, s^k-j^hilis, eczema, 

and liohen« oto, 
4. Uieletio en>u's, as in wine-ilrinkers* high liverss non- vegetarians, 

oto.» leading to the inoiv«iso of urea autl uno acid in the blood 
»». The lulvivulouH^ MMx^fulous, and lymphatic habitii, giving rise to 

nou-sjMvilu' eruption- ox,, im|vtig\^ aono. 
0, The j^uuv and rheum.^tie diatheMs, as in Uohon agrius. 
7, .Vltoixsl Mud IowoixhI nutrition fivm suoh causes as bail li\*ing, 

|Hn on \ , nuMM\ , 
x*^, rho aivuuudatuni \\( \'^\K-\>ci^ \\\ tho bUvvl fi\Mu non-oxcretion, sup- 

prevsiou of UAtund disohar^^« oto» 
;K l\m\ ;do>\>iMKV fivui M^xore and K^\>oviug dis*^a*t^ by which the 
Usl\ is U>«^ able to reNis; \u$ii>a»<\ 



ETIOLOGY. 17 

10. Climacteric, or eDdemic influences, oflen malarial in nature, which 
act by deteriorating the system generally, and give rise to the 
framboesia of the West Indies, the sibbens of Scotland, elephan- 
tiasis and its allies, the plica of Poland, the pellagra of Lom- 
bardy, the bucnemia, or Bai-badoes leg, the Aleppo evil, and Delhi 
boil, the cai*ate of New Granada, and the podelkoma, or Madura 
foot of India, and the guinea-worm disease of the Gold Coast 
and other parts. 
The above are the main influences that tend to disorder the blood-current, 
an(^ to induce the diseases whose elementary lesions have been described. 

B. There are certain states of mal-nutrition in which disordered tissue life 
seems to be the most prominent, as lupus, cancer, warts, corns. Local irri- 
tants that cause destruction of tissue i^ank here also, such as bums, scalds, 
parasites, the occupation of biicklayers, masons, and washei'women. 

C. Influences that play upon the nerves. Sometimes they are morbidly 
excitable, as in urticaria. All causes of debility tend to perverted innerva- 
tion, but as a rule local initants are those agencies that induce nerve dis- 
order, and lead to diseases in the skin. £x. : Want of cleanliness ; altera- 
tion of temperature ; undue exposure to the sun ; the action of ordinary 
local irritants ; occupation, giving rise to special causes of local irritation, 
as cooks, firemen, etc., who have their faces exposed to great heat. Then 
chronic visceral disease may be reflected tlirough nervous agency to the skin, 
and so uterine, gastric, intestinal aflections often give rise by " sympathy" 
to chronic congestion of the face and other cutaneous disorders. 

It is remarkable that the two leading dermatologists of the day — Wilson 
and Hebra — should totally disagree in regard to the comparative influence 
of the two great groups of causes, general and local. Hebra is the advocate 
of the local origin of skin diseases, Mr. Wilson of the general as well as the 
locaL I am entirely with Mr. Wilson. 

. Hebra says, ** Much more potent in the generation of diseases of the skin 
than the internal causes that have their seat in the organism itself, are those 
agencies which are external to the body, and which aflect the skin directly ; 
thus are produced the so-called idiopathic dermatoses.'*^ Among the exter- 
nal causes which he enumerates are climate, clothing, occupation, mode of 
life, atmospheric conditions, unwholesome handici-aft, pressiu-e, friction, con- 
tiision, scratching, neglect of cleanliness, too frequent or too energetic wash- 
ing and bathing, irritants used for medical purposes, such as rubefacients, 
epispastics, the moxa, etc., and epiphyta, dermatozoa, and epizoa. 

Now, in the instances of handicraft, pressure, friction, and cleanliness, 

Hebra can best establish his point ; but who will say that parasitic disease 

is entirely local ? There is a general condition of nutrition which must be 

present before fungi will flourish. The local cause often produces disease 

because it acts upon the surface of a debilitated subject. A middle course 

is the one we must adopt. In the majority of cases there is a predisposed 

state of system, and the actual disease is evoked by local agencies, 
2 



18 THE INFLUENCE OF FLANNEL AND SCRATCniNO. 

and these, as I have said, act frequently through the necves of the 
affected parts. 

Some of the causes have been called epli^meral^ such as in the acute speci- 
fic diseases ; some persistent^ as in lichen, psoiiasis, ichthyosis, cancer, lupun, 
and the like. Some come into action only once in a lifetime. Some are in 
constant oiyeiiition, others only at stated periods ; so that certain diseases 
are wont to appear at particular periods of life. 

Upon the nature of the ciiuse depends the contagions or non-contaffioui 
quality of any disease. It is generally held that parasitic diseases and the 
acute specific arc contagious. I shall describe a foinn of im[>etigo which is 
contagious. The special influence of age, hereditary transmission, occupa- 
tion, and heat, will be found in the oi>ening of the chapter on general diag- 
nosis. 

Sex has some influence on the cause of disease ; for instance, males suffer 
from sycosis, pemphigus, psoriasis, bucneniia, eczema, and epithelioma; 
and females from acne, kelis, and lupus eR[>ecially. 

The Influence of Flannel ami Scratching, — Oftentimes the simplest and 
most commonplace agencies, hai*mless in health, become active in the inten- 
sification of diseased conditions. This is the case with the wearing offlmh' 
nd next the skin. We scarcely need more than a i^eminder of the fact that 
some skins are so irritable in health as to be excited to an unbearable de- 
gree by the use of flannel, to undei-stand that whenever there is a tendency 
to exaltation of the sensibility of the skin, it may not only be heightened 
by the imtation of flamiel, but that this may also give rise to decided physi- 
cal alteration. In a very large number of cases of skin disease pruritus is 
in this way intensified and the disease even prot meted, and in proportion to 
the degi'ce of uncleanlincss. Flannel acts as a mechanical irriUuit, by aug- 
menting the local heat, and intensifying i-etiex action. When, therefoi^e, a 
congestive state of the skin, or any disposition to pniritus exists, the flan- 
nel should be taken off f I'om next the skin, and j)laced, if nec(;ssary, outside 
the linen ; — this will prevent any " catching cold." Tlie diseases in which 
this is advisable are, chiefly — erythemata, roseola, urticaria, certainly syphi- 
lodermata in their early stages, scabies, and prurigo. A remembrance of 
this little pi*actical })oint will sometimes give us the greatest cause to be 
thankful that we attended t^ it, trifling though it be. 

Scratching plays an important part in the modiflcation of skin diseases, 
most of which are accompanied by itching ; to relieve which, scratching is 
the natural to])ical application. What does it do ? 

1. When there is no eruption, it may produce one. For example, in 
pruritus, it gives rise to excoriations, an ai-tificial eczema, general enlarge- 
ment and turgescence of the follicles of the skin, with, perhaps, abrasion of 
the cuticle over and above them ; wheals in a ntittle-rash subjtHit ; ecthy- 
matous pustules in the ill-conditione<l. Of course in all these cases there is 
a bfiwis to go upon — a tendency to the several diseases produced. Scratch a 
healthy person, and the local injury is soon remedied. 



DISEASES DETEBMINED TO DIFFERENT PARTS. lO 

2. It augments and modifies existing eruptions. See in eczema how it 
inflames it, and increases the discharge and' subsequent crusting ; in lichen, 
the thickening of the derma. In scabies it gives rise to the peculiar 
" scratched lines " so characteristic of the disease, and many of the ecthy- 
matous pustules ; in prurigo, the peculiar ecchymosed apices of the papules, 
and helps out the coarse urtication. 

3. When the disease is non^contaffious, secretion, if present, may be trans- 
ferred from place to place; and if acrid, set up local inflammation; and 
when contagious^ scratching is the surest method of inoculation, as in the 
case of contagious impetigo. Children in this way ti^ansplant the disease 
from the liead to various parts of the body. Mothers, beyond a doubt, get 
the disease about their hands from contact with children. 

There are conditions liable to be overlooked, but which determine the 
local and immediate development of diseases in diflerent parts of the skin. 
These are not causes in the true sense of the word. I place them here more 
for reference than anything else. If there be some repetition, it will be 
excused for the sake of the completeness which will be given to the general 
survey of the pathology of disease intended to be contained in this section 
of the work. 

DISEASES ARE DETERMINED TO DIFFERENT PARTS, 

Amongst other things, by — 

1. The general or local nature of the cause. The whole skin is aflected, 

of course, in acute specific diseases. 

2. By physiological changes, in which the opportunity for the occurrence 

of disease is presented in the non-performance of some proper pro- 
cess. For instance, at pubei-ty the hair formation and gland func- 
tions of the skin ai*e called into activity, and any failure in the due 
formation of hair or the proper performance of the gland function 
may be a cause of disease, and this is the case in acne. 

3. The predilection of parasites for certain structures or parts — for in- 

stance, the hair in the case of fungi ; the interdigits and wrists on 
the part of acari, the pubis and the head, in reference to certain 
varieties of pediculi ; the parts kept warm and moist by flannel in 
the case of the fungus of chloasma. 

4. The special exposure of certain parts of the surface to external irri- 

tants — for instance, the face to the fire in cooks, or the face and the 
bared arms to the sun in out-door workers ; the bared legs in the 
case of the attacks of dracunculus disease ; the lower lip to pipe-irri- 
tation, evoking epithelioma ; the neck to the fiiction of the collar, 
inducing boils ; and various parts to scratching by the fingers. 

5. Anatomical peculiarities ; such, for instance, as the free circulation in 

the tissues of the face liable to be influenced by all changes of tem- 
perature. 



20 RELATIVE FREQUENCY OF THE DIFFERENT DISEASES. 

6. A failure in the proper correlation of function between the sldn and 

other organs, as when the kidney fails to act properly and throws 
greater work on the skin, which fails to perform the extra labor 
demanded of it, and so becomes disordered. The transmission of 
mischief by reflexion — for instance^ from stomach to face, or uterus 
to the face, should be mentioned here^ 

7. The contiguity to mucous surfaces, from whence inflammatory mischief 

may ti*avel to the skin. 

8. Auto-inoculation, as in contagioixs impetigo. 

9. Gravitation, as in the legs. 

10. The special affection of individual nerve trunks in connection with the 
seat of eruption, as in herpes zoster. 

RELATIVE FREQUENCY OF THE DIFFERENT DISEASES. 

Mr. Wilson has recently published " An Inquiry into the relative Fre- 
quency, the Duration, and Cause of Diseases of the Skin, as deduced from 
the Observation of 5,000 Consecutive Cases." * This gives a complete view 
of the matter as affecting the middle and upper, but not the lower classes. 
The diseases occurred as follow: — Of 5,000 cases 1,G77 (33 J per cent.) were 
eczema, 435 (8*70 j)er cent.) rosacea (or red rash of the face, especially in 
women), alphos (psoriasis and lepra), 314 (6*28 per cent.), acne 245 (4*90 
per cent.), alopecia 310 (6*20 per cent.), pityriasis 176 (3*52 per cent.), 
trichosia (ringworm) and scabies 107 and 184 respectively (2*14 and 3*08 
per cent.), lichen 177, area 130, and syphilodermata, 1G2 (3-62, 2-GO, 3-42 
per cent.). Then follow erythema 110 cases, chloasma 57, furuncle 50 and 
sycosis G4 each, prurigo 36, lupus (in all its forms taken together) 77, 
herpes and scrofuloderma 56 and 21, melasma 27, impetigo 58, xeroderma 
29, and nasvus 9. Then come cancer 25, kelis 14, urticaria 36, ecthyma 16, 
purpura 2, pemphigus 8, roseola 5, hordeolum 2, morphoea 5, bucnemia 1. 
Mr. Wilson further groups them together, and forms a clinical classification. 
Of the whole number 2,711 were eczematous (eczema, rosacea, lichen, scabies, 
and impetigo), 597 affections of the hair and hair follicles, 204 phytodermic 
(vegetable parasitic), psoriatic 314; then come sebiparous affections (acne, 
etc.) 284, strumous 98, syphilitic 162, alterations of color-function 52, ery- 
thematous 163, furuncular 72, nervous 71, pemphygoid 64, carcinomatous, 
25, etc. We may gain a very fair idea from the above figures of the general 
occurrence of skin diseases. 

♦ ** Journal of Cut. Med.," Jan. 1808. 



CHAPTER IV. 



CLASSIFICATION. 



The object of classification is so to group skin diseases together that the 
student may be able to obtain at once a general view of cutaneous maladies 
in their rough outline, and also to compare one disease with others with a 
view of tracing affinities between them. Much that has been said in the 
preceding chapter, will help towards a clear conception of what is tlie best 
classification ; inasmuch as it gave a general idea of the causes and the 
agencies operating disastrously on the skin. 

Skin diseases have been grouped in three chief ways : anatomically, patho- 
logically, iind clinically. In regard to the first two, no complete system 
has been devised, and it is self-evident that the best mode must certainly be 
that which collects diseases together, and arranges them side by side, in 
their mutual relationship, as exliibited in practice — ^in f&cty clinically. 
Plenck and Willan's classifications formed the first step towMds a clinical 
groupage, Alibert made an advance, and Mr. Wilson has still further 
developed the matter. The system of Willan and Bateman was follows : — 

Order 1. Papulcey including strophulus, lichen, prurigo. 

Order 2. Squamce^ including lepra, pityriasis, psoriasis, ichthyosis. 

Order 3. JSxanthenmtay including rubeola, roseola, scarlatina, purpura, urti- 
caria, erythema. 

Order 4. HuUce^ including erysipelas, pompholix, pemphigus. 

Order 5. PuatvlcBy including impetigo, variola, ponigo, scabies, ecthyma. 

Order 6. Vesicutas, including varicella, rupia, vaccinia, miliaria, herpes. 

Order 7. TuberctUa, including phyma, sycosis, verruca, lupus, elephantiasis, 
vitiligo, molluscum, acne, fi-ambcesia. 

Order 8. Maadcey including ephelis, spilus, nsevus. 

It is now quite conceded that some of the details in this arrangement are 
erroneous, and that the system requires development in accordance with 
recent advances in pathology. 

I have turned with no little anxiety to the new nomenclature of diseases 
prepared by the College of Physicians, to see whether any aid could be 
obtained towards the establishment of a new classification, but find that the 
detailed arrangement of diseases of the skin is altogether old and unsatis- 
factory. We are told in the preface that, after much consideration, the 
committee have resolved ^' That the proposed classification of disease should 
be based upon anatomical grounds,'^ and in subservience to that conclusion, 
the diseases of the body are found to be classified according as they aie 



22 CLASSIFICATION. 

gi^iionil or local. Now, changes in the skin are found in disea^s that rank 
in lH>th tht»sc classes, and the diseases in which they occur may be grouped 
aci^riliuij to tltt* arnuigi'nient nn^ommended by the College of Physicians, 
as follows : — 

1. (JenenU diseases, such as affect the whole fmrne rather than any spe- 
cial [mrt of it, divisible into two sections, A and B. 

S«HMit>u A, coiujaising diseases that "involve a morbid condition of the 
bUnnl, and which pn'sent for the most part, but not all of them, the follow- 
ing ohanicters : — 

•* Thev run a definite cimrst\ aiv attendini with fever, and frequently with 
eruptions t>f the skin, an» mon* or less rt^atlily conuuunicable from person to 
IM^rstUK and jh^nscsj* the singular and iui|H>rtant pn.>|>erty of generally pro- 
tfVting thoM* who sutfer them fr^un a sectTud attack. Tliey are apt to occur 
opidoniii*allv.** 

I'nder this head an^ ineludiHl the acuto specific or zymotic diseases, — 
oWdera, pl,-ig\ie, dengxie, typhus, typhoid, mlvola, scarlatina, yellow fever, 
small-jH^\ and its allies^ ivivbnvspinal fever, glanders, farcy, equinia, eiy- 
si]H'las, malignant pustule. In the majority of tliese diseases^ of course, 
the skin^misi'hief is of mnvndai'y imjH^rtaiuv, 

S^vtiow H •* cinupnjiin^, for the nuwt ivirt, disonlors which are apt to invade 
diiToivut j^rta of the same Ixnly simultauivusly or in succession. These 
aw siuuotiuu^ s]vken of as vvnstitutional dis^^a*^, and they often manifest 
a tondenov to trausmissi^ni bv iuheritaniv.*' 

Hert^ we ha\o Ivth rheumrttiNm and gv^ut, syphilis, cancer, lupus, rodent 
nbvv, tiue lepr\^sv, s»i^n^ful.t. puqnu-a, scurxy. Tlie definition of the rodent 
u)\vr, rts gixei; in tlic no\^ n»nuenolatun\ is ibis — •'a uestructiTe ulcer, 
obai-a^Mcuiisi b\ the extent uutl depth to >*hioh it >i»n^ds in the adjoining 
Ntvi^i^tui^^N a^.id b\ the ;d^>.-;uv ol* pixs\niiiig l.Aixiiitss^ ar.vi of constitutional 
a :V. ^ u I >u ; " b; s t :d\>i=< v. x\* ef t\ m i s ; i t \ 1 1 1 oua l a lT\ v t i » v. is v^i* e of i:* pnaminent 
f*>.stv,i\«. \\l;\ yU*\' i: tl.iu >Mth *vu>tin;ti. v.al d:si\ASrs> It may be a 
.;v,.^>:^-n whe;\»; lV*l,i !v.i\ tlie Alepp.^ e>i\.si;.i frsir.:\ii^Lu which are 
vv.^K-i^^ .^f Vv.;,h>v, v..,:e.\\\ .-♦v.*! eu»lon:io iv. .vvTc;.r. wisTiiois, siuMild not be 

:"" Fi . e >K\\v. , a V. ,s i ;. o ; mm on , a > ,\m » n-a>t \ r. j: >» : ; 1; ' \\s : * f gtn* ral. is local 
»;".v...^>.,^v, ,v. .1 V.^'iN- :V,»"^.\ ;x .^ ;\\-,' s;o:n r.;a*ie v.; t\•^>^^i '*'* 'ho plan mq^pested 
tI- ;:..^ s^.i-s^o V.-..-.: .^t* */. \v:.: ,;;^\-^s.«k VV.o :.v\>: »:;ni^A5<^ in the College 
xf r:xx:. ..vx* V, .. ..,_^^v •.v4:,v,i.M ;,v M X , ;>%.:^ tV,'.;;.^: v.iider one of the 
VvV.o^n .'..»; ■.ASi.N V..'av y.-.;^-.o'x^ :., oAtAnl^A^, v.^vrAiivo, Mspparmtive, 
V-sMv, ; .-. ., •/..-.■.,,., ^ c-.:x. ^*.'^) ^,ty.'»'.- \ ^i- ' ^.r-;rWrt«, and 
j?.v..N5-.\»'ivx: iv.:V. •■.:-.*,., v. i>.;-..v'v- .^. ivivx'.xv ,\v. ;?**>::. v. : baMBwrrfia^, 

lV-:.>x V :•.■.:.;.> ,:.:x^v,; \ :.:•:.: ;,-•; ,M- .:;:.v-v'. .: s^ l-cluding dilaU- 

''•■-- 'V\..-'», .;...: x-v .-, ;. X, N-:v...Vx, ,t, j^ ;,, ^i^.^t , "f;*.:^ Al^.i <»iOirP0US. 



CLA88IFICATIONJ. 23 

disease. * CAlculus and concretion. Malformation, (ddi) Injury. (1014) 
Foreign body. Functional diseases. The dibe&ses printed in italics are 
dii'ected-to be returned, in any classification of disease that may be made 
for statistical purposes, not among the local diseases, but under the head- 
ings refened to by number; which are, in the. case of 31, Section A of 
general diseases, and the others Section B 6f geniei^l diseases before refer- 
red to. ^! / 

Now, this plan is dii*ected to be applied to the grouping and description 
of the various local diseases of the ear, mouth, nose, circulatory, digestive, 
respiratory systems, etc., but this has not been done in the case of diseases 
of the skin : they are indeed the only exception, and that is why I stated 
at the outset that the detailed ari*augement of diseases of the skin in 
the new nomenclature report was old and unsatisfactoiy. I shall supply 
the omission as far as possible, making catarrhal : pla.stic : suppurative : 
gangrenous inflammations of the skin, etc., in agreement with the College 
plan, as that is entirely in accord with my views of cutaneous pathology. 
Now, with the aid of these particulars, and in conformity therewith, let us 
see what are the diseases in which the skin is specially affected. We have 
the following diseases to deal with : — 

1. Eruptions in acute specific diseases. 

2. Skin changes in constitutional diseases : sypliilis, struma, cancer, lupus 

(? local), rodent ulcer (? local), leprous (elephantiasis). 

3. Local inflammations, which, according to the views I entertain, would 

be arranged thus : erythematous or congestive : catarrhal (eczema) : 
plastic (lichen) : suppurative or pustular : ulcerative : gangre- 
nous, etc. 

4. Haemorrhages. 

6. Degenerations, lardaceous disease. 

6. Parasitic. 

7. Hypertrophies and atrophies. 

But these do not include all. We have besides, bullous and squamous 
diseases, disorders of the special structures of the skin, (a) of pigment for- 
mation, (6) of the nerve supply, (c) of the vessels j (d) of the glands of the 
skin. 

Going a step farther, we may construct the following classification, which 
is the clinical scheme of Mr. Wilson, somewhat condensed : — 

1. Zymotic diseases (eruptions of acute specific diseases). 

2. Local dermal inflammations, — erythematous : catarrhal or eczematous r 

plastic or lichenous : suppurative or pustular : bullous. 

3. Diathetic, including strumous, cancerous, syphilitic, leprous (or true 

leprosy), and alphous (or lepra vulgaris) diseases. 

4. Hypertrophic and atrophic diseases. 
6. Hamorrhagic (purpura). 

6. Neurotic or nerve disorder, pruritus, prurigo, etc. 

7. Chromatogenous or pigmentary alteration. 



24 CLASSIFICATION. 

8. Parasitic, animal and vegetable. • 

9. Diseases of the glands and appendages of the i^kin. 

This is the classification which I recommend the student to adopt. 

There are those who will miss the gi*oup squamous ; it has usually in- 
cluded pityriasis, which ranks with epithelial hypertrophy: ichthyosis, 
which is only a part of general ati'ophy of the skin : and lepra vulgaris, 
which is a very special disease, that I have grouped under the term alphous. 
It is impossible that three such dissimilar diseases can be classed together 
under the term squamous. (See Summary,) 



CHAPTER V. 

GENERAL DIAGNOSIS, PROGNOSIS, AND TREATMENT. 

I. GENERAL DIAGNOSIS. 

In making a diagnosis we should remember that modifications of disease are 
brought about by diathesis, by chronicity, by remedies, by scratching, by 
abortive development, and by the intermingling or coexistence of two or 
more different diseases. The following are the " points" in diagnosis which 
we should carefully note in the first instance. 

THE MODE OF ONSET. 

The majority of cases of diseases of the skin are not preceded or even 
accompanied by severe constitutional disturbance; if there happen to be 
much fever and malaise, especially when the patient takes to bed from a 
sheer feeling of illness, and an eruption begins to show, we suspect some- 
thing grave, one of the acute specific diseases probably. However, amongst 
the occasional exceptions, acute lichen, erythema nodosum, secondary 
syphilis, acute eczema, pityriasis rubi-a, acute pemphigus, urticaria, herpes 
zoster, and erysipelas may be named. Secondary sypliilis has been mistaken 
for the mottling of typhus and measles, acute lichen for measles, and herpes 
zoster for pleurisy, on account of the pain. It is merely necessaiy to be 
aware of these mistakes to avoid them. Occasionally in eczema there may 
be marked pyrexia. When symmetrical, the disease is usually due to a 
blood-poison ; when unsymmetrical, to local causes or perhaps affections of 
the nervous trunks. 

TEMPERAMENT. 

We are generally enabled to say at a glance whether our patient is of full 
habit and likely to have a loaded system : especially the case in women ; 
whether there be organic disease, or if there be a dyspeptic habit, or an ill- 
fed system, that signifies debility. If lymphaticy the patient may have 
eczema, impetigo, intertrigo, the pustular aspect of scabies and ringworm ; 
if gouty y the scaly diseases, chronic eczema, and lichen agrius ; if rheuDiaticj 
erythema nodosum ; if strumous^ eczema, lupus ; if florid^ alphos especially. 
There is also the cancerous cachexia, and in nervous subjects various hyper- 
8e8theai» engrafted upon ordinary eruptions. Red-haired subjects get pity- 
riasis of the scalp. 

THE DURATION OF THE DISEASE. 

Sereditary diseases are chiefly — ^lepra, psoriasis, ichthyosis, lichen, ecze- 
ma, and syphiloderma. 



26 GENERAL DIAGNOSIS. 

Conf/r.nitfd dweasos — syi>liilodermata, pemphigus, pigmentary, n»ya8, 
and icrlitliyosis (Bcalos). 

Chiumlcitij. — The more chronic a disease .'is the more does it tend to be- 
cohh; a local diHoase ; and this is the case with hereditary affections (hence 
in these cases 7t>ra/ treatment is the most important). 

THE RECURRENCE OF THE DISEASE. 

L<'pra and sy[)hilitic diseases are essentially those which recur. 

0(X?UPATION OF TUE ATTACKED. 

Cooks ^^i eczcnna and erythema, and witli bakers, grocers, and bricklayers 
lichon agrius about the l)acks of the hands ; cliimney-sweepers are liable to 
(*pith('H()ina of the scrotum ; cotton-workers to urticaria; butchers andgra* 
ziors to whitlow, boilH, and malignant pustule ; dragoons and shoemakers to 
ecxoma nmrpnatum in the fork of the thighs; yoimg women who come 
from tlu! rouiitry and have the full diet faix) of the London servants, get an 
ov(»rloadi'd KyNtom tliat shows itself in eiythema papulatum, erythema no- 
dosuu), or imi>etigo ; butchers fretjuently get ecthyma. 

AGE OF THE PATIENT. 

Tliis is very important. During the first six weeks of life congenital 
syphilis develops itself; intertrigo, eczema of the scalp, and seborrhcea 
capillitii also occur about the same time. Syiihilitic i)emphigus occurs, it 
is saitl, Wfoix* the child is six months old, not aft<?rwards ; during the first 
few months and up to and through the i>eriod of dentition, strophulus and 
cH»zema ai>^ met with. I n<HHl only mention important facts. Cancer (epi- 
thelit>m;0 is a disease of late life— not In^foro thirty ; about sixty : and ro- 
dent uloer alH>ut the agi» of sixty ami In^yond. Lupus is a disease whiich 
ctuumeuees in early and young life, and the same may be said of syphiUa. 
The pan»sitio iliseases oeeur in the ytning, nm»ly after twenty-one years of 
ag«\ H(MiH\s eiivinatvis (or, as J call it, tinea oircinata) is the form seen in 
adult life. In ohl p(»opK», prurig«>, ecthyma cachecticum, pemphigus, and 
pnu'itns, witli e«ni^»r and rodi»nt idcor, iH*cur. 



THE 8KAT OK DIBRASE. 




GBNERAL DIAGNOSIS. 27 

tinguislied from eczema on the inner and front aspects ; dhows and kheesy 
lepra, psoriasis ; inierdigits and about wrists^ scabies ; hack of hamis, lichen 
and grocers' and bakers' itch ; palm of hands alone, syphilitic lepra and ery- 
thema ; . hvMocks and feet of children^ scabies ; upper line of penis y scabies ; 
gcrotuniy eczema, psoriasis, and epithelioma in chimney-sweepers ; front of 
leg, erythema nodosum, and in old people, eczema rubinim ; ahout the anus 
in children, congenital syphilis ; travelling or developing, and affecting gen* 
erally over the hodi/y pemphigus foliaceus and pityriasis rubra; in the hend 
of joints and armpitSy eczema rubrum ; and limited to the hair foUicleSy 
lichen and pityriasis pilaris ; and to these and the sehaceous glandsy lichen 
Bcrof ulosus and lichen ruber. 

It is important to ascertain if the eruption be persistent or evanescent 
(urticaria), developed pretty much at once (acute specific diseases, heri)es 
zoster, herpes), or ^onsectUivey and particularly if uniform or midtiform : 
the latter being the character especially of scabies and syphilodermata. It 
is (rarely) seen in the complication of scabies by impetigo contagiosa ; urti- 
caria, and scabies, or purpura ; scabies and prurigo, eczema and scabies, ec- 
zema and lichen (eczema lichenodes), eczema and psoriaais, oftentimes in the 
fork of the thighs and about the bend and front of the elbow. This fact of 
the intermingling of diseases is one of the most important to remember ; to 
forget it is to lay one's self open to one of the commonest sources of error. 

We scrutinize closely the character of the eruption to ascertain the primi- 
tive elementary lesion. This is the clue to the nature of the eruption. 

I will now give the 

DIAGNOSTIC FEATURES OF ERUPTIONS. 

MacvilcB (see pp. 6 — 20). 

JErythemata, — There is no need to particularize that of the acute specific 
diseasies. Mistakes generally occur with roseola, which is confounded with 
erythema papulatum and rubeola ; but it is never accompanied by distinct 
catarrh ; it is rose-colored at first, gradually getting duller, non-crescentic, 
occurring in circular patches from half an inch to an inch in diameter ; not 
on the face ; it is often very partia]. In acute diseases erythema oftentimes 
occurs about the arms and limbs, as in cholera or rheumatism. Ordinary 
erythema i^ of a darker hue than roseola : it has a bluish tinge at its edge, 
and is not so well defined — L 6., is more diffuse. £rythema may also arise 
from friction ; from tension, as in cedema ; from medicinal substances, as 
henbane, arsenic, belladonna, copaiba ; and after operations, when it is often 
pysBmic. The erythema of erysipelas is accompanied by tension, shining, 
smarting, and swelling. £. scarlatiniforme presents all the characters, as 
regards the rash, of scarlatina, but lacks its general throat symptoms and 
the peculiar appearance of the tongue. The rash is seen about the; neck, 
the flexures of the joints, and the trunk ; it lasts five or six days, and is 
often more or less evanescent. The rosalia of authors — rubeola notha, or 
rubella — holds the same relation to rubeola that E. scarlatiniforme does to 



S8 OENEKAL DUGKOBie. ^^H 

scarlet fever — that is to say, there is an absence of the general symptoBfl^l 
whilst the eniptiou is similar. In all these eases of acute febrile erytlu^' 
mata desquamation is observed. In every instance tUe redness disappears 
or is removable by pressure, unlike that of purpura or |>el1agra. lu lupus 
erytheroatodes an erythema like chilblains is conimoa ; it occurs in summer 
as well aa in winter, and ia eonnectsd with loss of hair, etc. The eiytheraa 
of urtieoria is very easily diagnosed : a slight scratching with tlie null will 
produce a wheal. 

Pajnila on the outer nsjiect of the limba, with a thickened dull state of 
skin, constitute lichen ; those with slightly dark apices (coagulated blood), 
occur on the arms and anterior aspect of the trunk, as a complication of scabies 
and ol strophulus (pruriginosus) in children ; to a marked extent seen in pru- 
rigo, accompanied mostly by an inelastic state of skin and the " broad" papules 
formedhy on exaggeration of the little areas enclosed by the natural fiu'rowa of 
the skin: intermingled with vesicles and pustules in scabies; soft and red, and 
witherythemainchildi-en, in strophulus; flat and reddish, collected together in 
little parcels, though discrete, lichen ruber ; aggregated and confluent, lichen 
circutuscriptiis ; formed about the hail' follicles, lichen pilaris, pityriasis pilaris, 
lichen scrofulosiiB, and the lichen of phthisis. The most common mistake, 
that of confountling lichen and scabies, is at once avoided by observing the 
multiform aspect of the latter and the unifoi-m character of the former. 

Those eruptions in which vesicles and pustules occur are eminently char- 
act«iized by the occurrence of discharge ; and this at once divides diseaaea 
into two great classes : in the one cIbsm, where secretion or discharge occura, 
eruKU foiin ; in the other, ci'usts are entii'ely absent. Ulcerative diseases 
are easily recognised. The character of the aecretwn affords moat reliable 
information. If thei'e be sorosity, without crusts, it ia intertrigo ; if tbin, 
few, Himsy, light-colored crAsta form, and the discharge stiffen linen, it is 
eczema : if the crusts be a little thiclcer and in little circular jiatches, herpes 
or vesicular scabies. SfTn-pinnUent, with slight yellow crusts, eoxema im- 
petiginodes ; or if stuck on and flattened, impetigo contagiosa ; pimdtnt, 
forming thick crusts of a yellow color, hecniuiug more or leas dark, ec- 
thyma, furunculuB, purulent scabies, imp«Ugo sycoaiforme, impetigo scabida, 
sycosis ; and if oockle-shapcd, nijiia, of course. iSanUnm, rupia and ecthy- 
ma cachecticum. Fatty, acne sebacea, seborrhoia, sebaceous ichthyosis 
(legs), JTafouirrhagic, htemidrosis, etc. 

We must distinguish scales from crusts : scales ai'e altered epithelial cells, 
fiednees with scales, lasting on to chrouicity, is seen in tinea circiunta, ery- 
thema circinatum, and herpes iris. Scales, as a primary formation, if pai-- 
tial, in lepra; if general, ichthyosis. 

Tubermiia. — ITiere are four diseases somewhat alike, in which " tubercula" 
occur : tlieir characters are an follows : — 

Cntterr ('^lit/idioiita) tubernilfS. — Solitary, flat, lianl, and tender. Scabs 
Blight. When idceration seta iu the glands enlarge. There is much infll- 
tMtion around the ulcer, which ia pajiillated, dirty- givyish, iohorous, or 



THE PROGNOSIS. 29 

semi-scabbed, with hard, everted, and undermined edges. Epithelial ele- 
ments may be seen by the microscope. 

Hodent tUcer begins as a small, pale, pretty soft tubercle, of very slow 
growth, almost painless, giving rise to an ulcer, without glandular enlarge- 
ment, presenting a clear surface, not papillary, without ichor, but with /tare/, 
sinuous, non-everted, and non-undermined edges. 

IJupus has at its base an erythema that looks like searing ; then upon this- 
arise dullish-red, soflish, round, gelatinous-looking tubercles, forming patches 
of various extent. Thin adherent crusts form. There is no pain. The 
course is indolent. The edges of the patches are inflammatory, rounded, 
and raised, but not everted. There is always a tendency to repair, and 
cicatrices form, accompanied by distinct loss of substance. 

SyphUia, — Tubercles commence as papules ; they become hard, large, 
and flattish, but not so flat as those of lupus ; they are dull-rod at fli-st, 
then coppery, and disposed in circles, or serpiginous, covered by thick dark 
scales. There is an. ulcerating and a non-ulcerating form, the ulceration 
being often serpiginous and misnamed " lupus*" Syphilitic tubercles often 
occur about the face. The ulceration is dirty, ashy gray, sloughy, and 
ichorous, the edges shai-ply cut and everted, surrounded by tubercles of a 
copper tint. 

With regard to parasitic diseases, no serious difliculty ought to arise if a 
microscope is at hand. Nevertheless, favus and impetigo are confounded 
with lepra, eczema, and tinea tonsurans, notwithstanding the cupped-crust 
favi of the former and the dry nibbled patches of the latter, in which the 
epithelial cells and hairs are freely invaded by the fungus, when this is 
easily detected. Chloasma, with its itching and desquamation, is very 
frequently indeed mistaken for syphilitic maculae. Sycosis is often non- 
parasitic ; in this case, the damaged split-up hairs will be absent, whilst the 
disease travels up into the whiskers. 

- I hope that this section is so arranged as to constitute a general diagnos- 
tic chart. 

II. THE PBOONOSIS. 

Skin diseases are rarely fatal. When they occur as secondary manifesta- 
tions implanted upon already existing disease, especially those of long-stand- 
ing and in debilitated subjects, they are to be regarded according to their 
extent and nature as indications for grave anxiety. However, pemphigus 
neonatorum, ecthyma cachecticum, rupia, pemphigus foliaceus, are most 
likely to be followed by fatal results. Malignant diseases, of course, have 
a fatal issue. The sudden retrocession of cutaneous eruption is generally 
considered a most prolific cause of serious consequences ; there can be no 
question that the latter frequently follow the former, but the modus operandi 
of the supposed cause is uncertain. 

Hereditary tendencies, especially when exhibited in a congenital manner, 
render the cure exceedingly difficult ; in some cases, for example ichthyosis, 



80 THERAPEUnCfl. 

impossible. Tlie older the patient is before hereditary predisposition shows 
itself, the moi-e likely is he to get well. The presence of the scrofulous or 
syphilitic habit, mal-hygiene of all kinds, frequent recurrence, coexistent 
disorder of the mucous surfaces, such as ophthalmia, otitis, muco-enteritLs^ 
local degenei-ations of tissue (as in acne rosacea), the fact of a disease 
having become very chronic, symmetrical arrangement of the eruption, 
intemperate habits, dyspepsia, uterine disorders (such as leucorrhoea), denti- 
tion, old age, or very young age, all conduce to protract and render the cure 
difficult. 

As a general rule, a prognosis is rcqiiired, not as regards fatality or 
danger, but the difficulty of cure, and particularly the likelihood of recur- 
rence. Lepra, ]>soriasis, ichthyosis, erysipelas, eczema, urticaria, and lichen, 
are the most likely to recur. 

All parasitic diseases are curable, and this depends upon the facility with 
which the parasite can be attacked and destroyed. In case of loss of hair, 
a cure is said to be impossible if the hair has been lost pretty suddenly ; 
and generally, if there hapi)ens no subsequent attempt at reformation, the 
scalp at the same time being white, shining, tense, lowered in sensibility, 
and apparently with atix)p)iied and indistinct follicles. In all cases of skin 
disease the earlier the patient comes under treatment the more likely is he 
to get rid of the cutaneous eruption ; in other words, the most important 
point as regards speedy cure is early treatment, before the disease has had 
time to become localized. 

III. THERAPEUTICS. 

Bearing in mind what has been said, and especially having regard to the 
classitication I have adopted, it is easy to see that the same principlei of 
treatment which are applicable to diseases of the body generally, must be 
adopted in reference to affections of the skin. The basis of most cutaneous 
eruptions is itkjlamnmtion — that must be treated upon ordinary principles ; 
we must not forget tliat, in the early states of eruptive disease, local irrita- 
tion plays a verj' prominent part. 

One of our chief aims should be to check and prevent this, adopting as 
much aa |)osKiblc a soothing plan of treatment. This does not appear to be 
the generally rweived opinion ; nay, the empiricism of modem time has an 
exactly op|>08ite tentlency, and it is decidedly true that many treat skin 
diseases by attempting to overwhelm by medicinal action the natural 
progress of the disease. In a therapeutical point of view, skin diseases 
divide themselves into two classes — those which are purely local, and those 
which are general. Among the local, practically speaking, are parasitical, 
papillary, imvoid, hypertrophies of normal structures, such as molluscum, 
keloid, horns; certain pigmentary changes; chilblains, bums, scalds, etc 
Among the general are blooil diseases of acute and specific eiuiracter, which 
require mere conduction through their natorml stages ; others are due to 
various degrees of debility, demanding geneiai tonio or alterative action, 



THERAPEUTICS. 31 

or the employment of specific remedies. In all cases special attention must 
be directed to the influence of diathesis; the gouty, the scrofulous, the 
rheumatic, the sanguineous, the syphilitic, the dartrous, etc., call for their 
appropriate remedies irrespective of the kind of local eruption ; or, to put 
it in another way, the general treatment varies in the same disease accord- 
ing to the general aspect of the patient ; all deviations from the standard of 
health must be rectified before or in conjunction with the employment of 
fecial medicines. In a large number of cases, disorders of the general 
• health which appear to have little connection with the miscliief, are the 
exciting or determining causes. In reference to local treatment in the 
general diseases, the idea is to soothe the part at the outset, in the secretoiy 
stage, to use alkaline washes and slight astiingents ; in the quiescent or 
early chronic stage, mild stimulants, absorbents, and Anally revulsives; 
taking care in all cases to remove crusts, scales, and such like by {)oulticing, 
warm foments, or greasy applications. In the very young the health of 
the nurse requires attention, and it is often advisable to make the milk of 
the nurse the medium of medicinal action. The use of irritants is to 
be specially avoided in the young, whose skin is delicate. In all wet 
diseases (the secretory) the local remedies should be used in a liquid 
form; in the dry, in the- form of ointment; the formation of thick 
crusts do^ not seem to be favorable to the use of ointments. 

The free action of the kidneys must be carefully enforced. It is one of 
the most important points in treatment. In chronic diseases, dyspepsia is 
often present. In the secretoiy aspects, purgatives do good. Antiphlogistic 
Temedies are bloodletting, emollients — c.(/., the tepid bath, mucilaginous 
and acidulated drinks, but especially the acetates of anmionia and potash. 
When we wish to preserve the eruption from being injured for fear of 
ulceration, as in zona, pemphigus, and rupia, we employ mucilaginous fluids 
— -e.ff.y oatmeal gruel; or even absorbent powders — e.(/., lycopodium. 
Local maceration, by glycerine especially, is useful in hard, diy, cracked 
states — e,(/.y psoriasis palmaris. Irritation, if general, is allayed by tepid 
sponging, gelatinous and alkaline baths. Baths are useful for purposes of 
cleanliiiess, also as antiphlogistics, as soothing agencies, and as a means of 
employing various medicines. The anti-scrofulous remedies are cod-liver 
oil, iodide^ of iron and potassium internally, and iodide ointments, iodine 
baths, and the like externally. The anti-herpetic, as they are called, are 
typifled by sulphur. The nervine tonics are quinine, alkalies, aconite and 
strychnine, alkaline baths. The anti-syphilitic are bichloride of mercury 
and iodide of 2>otassium internally, and mercurial ointments externally. 
The gouty remedies are colchicum and alkalies, etc. The sanguineous, 
antimonials, etc. The anti-squamous remedies are arsenic internally and 
tar externally. I fear to add further detail on account of repetition. 



CHAPTER TI, 

THE ERUPTIONS OF ACUTE SPECIFIC DISEASES (ZVMOTIC)— WHICH ARE OP CON- 
TAGIOUS NATUKE, OF DEFINITE COURSE AND DURATION, ACCOMPANIED BY 
FEVER, THE RESULT OF POISONING OF THE BLOOD BY SPECIAL VIRUSES- 
ONE OF THE EFFECTS BEING THE DEVELOPMENT OF CERTAIN ERUPTIONS ON 
THE SKIN. 

These need not be dwelt upon at any length, at the same time it is neces- 
sary to give a short summary of the eni2)tions themselves, for diagnostic 
purj)08e«. 

VARIOLA, OR SMALL-POX. 

The skin affection is characterized by the appeai*ance of bright red hard 
acuminated points, distinct from each other at first, the size of hemp seeds, 
which, passing tlirough the stages of vesicular and pustular inflammation, 
ai-rive at their maturity on the eightli day of ei*uption, when they scab into 
a dry brown mass, which becomes detached in from twelve to twenty days, 
leaving behind permanent cicatrices or "pits." Small-pox is often pre- 
ceded, as regards its local state, by more or less erythema, which subsides 
on the appearance of the vari. Small-pox is said to be discrete^ when the 
pustules are scattered ; coherent^ when the eiiiption is plentiful, and the 
vari ai"o " closely packed side by side but still distinct ; " conflu^itj when 
they run together ; modified^ if succeeding to a prior attack or inoculation. 
Tlic disease is also primary or secondary, as regards the number of attacks. 
Variola sine A'ariolis is the name given to the febrile attacks which are un- 
attended by eruption. The mucous surfaces are affected in like manner to 
the skin. Small-pox is, by universal consent, divided into five stages, — 
incubation, the length of time which elapses between exposure to the poison 
of the disease, and the development of the firet effects, (5 — 20 days — Dr. 
Mai*son, of the Small-pox Hospital, says 12) : invasion (2 days) : eruption : 
suppuration : and desiccation. 

llie " Period of J'Jrujyt'wny — Eruption makes its appearance on the third 
day after the first appearance of constitutional disturbance, and travels over 
the entire body witliin a day, when the febrile condition is greatly relieved. 
The spots show fii*st on the face about the foi*ehead, and thence extend to 
trunk and limbs. Tliese spotij are, in the very outset, small papules, red, 
hanl, pointed, more or less closely packed or sc^ittered, affording a good 
guide as to whether the disease will be confluent or not ; if the skin be veiy 
red and erythematous, probably the case will assume the confluent form. 
On the second day of eiiiption — fourth of disease — the papules get trans- 



-.d 



MODIFIED VARIOLA. 33 

formed into vesicles ; but if these be punctured, nothing escapes ; on the 
third day of eruption — fifth of disease — umbilication commences as a cen- 
tral depression, which becomes more marked every day, pari pass^i with 
suppuration ; the pustules are ** whitish and surrounded by an inflamed 
areola " (fourth day of einiption — sixth of disease) : if the contents of the 
pustule ai-e now turned out, a little " disc " of dirty plastic matter, present- 
ing an umbilicated shape, and attached to the cutis beneath, will be noticed. 
In the confluent form these changes are not distinctly seen. It is not at all 
unusual to observe the confluent in one, the discrete form in another part 
of the same subject. The onset of Maturation is observed about the end 
of the fifth or beginning of the sixth day of eruption, eighth of disease. 
The contents of the umbilicated vesicle soften down into pus, the umbilica- 
tion diminishes with enlai*gement of the base of the pustule, and a yellow 
color replaces the white ; the contents are the same plastic disc and pus. 
Maturation, as it is called, is *' complete on the eighth day of eruption," 
tentli of disease ; between the eighth and eleventh day, tenth or thii-teenth 
of disease, secondary fever sets in, when the stage of Desiccation is reached. 
This is the period of recovery or resolution, when the local and general 
symptoms subside, the scabbing dries, and the discharge ceases, the crusts 
fall off in the next tliree or four days (fifteenth day of disease), exposing 
raw red surfaces, which desquamate, and by-and-by leave behind red-looking 
marks, which gradually fade and assume the well-known aspect of small- 
pox marks. When small-pox is produced by inoculation there are some 
differences. On the third day the puncture is inflamed, it is itchy, and sur- 
rounded by a little blush of redness, the spot too is slightly indurated ; on 
the fourth or fifth day the central point acuminates, and a little coming 
vesicle is seen ; on the sixth day there is an early state of pustule, and it is 
umbilicated ; seventh day, a pustule (inflamed) is formed with an inflamed 
areola; ninth to tenth day, maturation takes place, umbilication goes; 
twelve to fifteen days, desiccation takes place ; twenty to twenty-five days, 
the scab falls off. The disease is rarely confluent. 

MODIFIED VARIOLA. 

The effect of vaccination is to lessen the severity of variola, and the dis* 
ease occurring in vaccinated subjects ia called modified small-pox. 

There are differences of opinion as to whether there is any relation be- 
tween it and varicella. The distinction of varicella (vesicular), modified 
small-pox (varioloid, as it has been termed), and variola is well marked in 
the extreme degrees of either disease, but they shade the one into the other 
by insensible stages. At times one meets with cases which may be called 
either vaiiola or varioloid, — indeed it is not uncommon to observe the vesic- 
ular in conjunction with the umbilicated form; at other times the eruption 
is simply papular and scarcely reaches the vesicular stage, yet is traceable 
to the action of the small-pox poison. Varicella has been regarded as small- 
8 



34 VABICELLA. 

pox modified by vaccination, but there is good reason to look upon it as a 
distinct disease. 

In modified A'ariola, as compai*ed with time A'ariola, the secondary fever is 
absent : the only stages present are those of primary fever and eruption. 
As a rule the pyrexial symptoms partake of the character of those of vari- 
ola, but are of less severity. The eruption may be papular ; it observes the 
same behavior as that of variola in the outset, only it is abortive at the 
papular stage, and in a few days the papulte subside ; there are a few vesic- 
ular and pustular spots geuei-ally about the face. At other times the 
vesicular stage is reached, and lasts five or six days, and, as in the papular 
variety, there are a few pustular spots on the face. In more marked in- 
stances, the modified variola is pustular, and the pustules may be globular 
(the A'aricella globulaiis of Willan, and swine pox of old authors) or um- 
bilicated, or the characters of these two varieties may be intermingled with 
conical vesicles. In other words, modified small-pox may abort in any of 
the stages which are passed through by ordinary variola. 

VABICELLA. 

This is a disease of children. Afler pyrexia of a few hours, or not more 
than twenty-four, the eruption of A^aricella appears, often on the back first 
of all, as distinct red papulie, which become vesicular in a few hours : the 
eruption is successive during three or four days. The same kind of changes 
in the eruption occur as in variola, but the disease is more superficial and 
the vesicle is unilocular, it is not umbilicated ; the contents are serous. On 
the first day the vesicles are transparent, opalescent on the second and third 
day, on the fourth they shiink and desiccate, and on the sixth the scabs 
fall off. Sometimes the contents of the vesicles become puriform. The 
general symptoms are slight. 

It is diagnosed from the vesicular variety of modified variola, by less se- 
venty in the anteceiltMit p^-rexia, the absence of the '* shotty " feel of the erup- 
tion in its papular stagi*, the rapid formation of the vesicles, the absence of 
much indamnmtory local hanlness, the successive crops of eruption, its com- 
mencement on |iarts other than the face, the absence of pitting, the super- 
ficial character and the shortness of the course of the disease, and the absence 
of secondary fever. The diseaise is over in a week or so. 

IXOCrLATED VACCINA, OR VACCINATION. 

On the third day after vaccination there is seen a slight red point if a 
puncture, or a re<l eilge if a scratch, has been made ; the part is also eleva- 
ted. On the fourth day these signs have augmented ; the jtapular stage ia 
attained; there is local irritation; the edges of the wound are everted, 
thickened, inflamed, hot, with a commencing blush of reilness aroimd. Hie 
disease may subside at this stage ; usually on the fifth day the epidermis is 
raised into a vesicle, which is decideil on the sixth day, when it is of a whitish 
color, round or roundish, and with commencing umbilicatiou. It attains 



TYPHUS RASH. 35 

its full size on the eighth day (fifth of eruption), it is distended, flattened, 
whitish, and sun*ounded by a red areola, and more or less induration ; the 
parts around now becopie irritated, tense, brawny ; the glands enlarge ; the 
blush of inflammation extends oftentimes to the shpulder, or down the arm 
itself. On the ninth day the umbilication is lost, and the pox is getting 
pustular. If the vesicle is punctured, aroimd the edge especially, a transpa- 
rent fluid exudes. On the eleventh day, the blush of inflammation begins to 
subside ; the contents are pustular, and the stage of desiccation commences. 
Up to this period the vaccine vesicle is chambered, so to speak, into sep- 
arate cells ; these now open the one into the other^ and form one large pus- 
tule; the desiccation advances from the centre in the next few days (12th, 
13th, 14th) towards the circumference ; the ciiist dries also, so that a dark, 
hard, diy, shiivelled scab remains ; the redness has in great measure gone, 
but there is a lividity about the vesicle ; the crust separates from the seven- 
teenth to the twenty-fifth day, leaving behind cicatrices, at firat of dark color, 
which are permanent. Mr. Wilson, who is so excessively clear and definite 
in all his descriptions touching variola, recapitulates thus in regard to the 
stages of the disease. 

First two or three days, incubation / 4th, papidar / 5th to 8th, vesicular 
(umbilication) ; 8th day, areola / 9th to 1 1th, pustular j umbilication lost, 
areola enlarged ; Idth to 17th, period of separation, 

TYPHUS RASH. 

This consists of two component parts : — 

1. A subcutaneous mottling, of a more or less livid hue, and diflused gen- 
erally over the body. 

2. Petechice, small, about the size of pins' heads, scattered all over the 
body, and showing out fi*om the mottling ; at first these are slightly raised, 
and their color increases gradually in intensity ; they do not fade by pres- 
sure, except slightly, in the very early stages. The eruption of tyi>hus is 
not prolonged by successive crops. It makes its appeai*ance between the fifth 
and eighth day of disease, and disappears a few days before convalescence. 

TYPHOID RASH 

Is characterized by the appearance between the eighth and twelfth day of 
disease of rose-colored, elevated, circular, softish spots, about a line or so in 
diameter, on the abdomen, back of hand, arms, chest, and back (if kept 
warm). They disappear by pressure, appear in successive crops, each spot 
lasting three or four days, and then gradually fading. There may be from 
half a dozen to a score at one and the same time present. Sudamina often 
coexist. 

RUBEOLA (measles), OR MORBILLI. 

About the fourth day after taking ill with catarrhal symptoms the erup- 
tion appears, first on the face, especially the forehead, then on the chest 



36 BCABLATINA. 

and limbs ; it reaches its height in the former situation in about two days, 
when it begins to fade. These changes are a little later on the other parts 
of the body. The eruption lasts altogether about four or five days, and 
leaves behind sometimes little, at other times a marked amount of desqua- 
mation, perhaps a good deal of mottling or red staining, e8i>ecially if the cir- 
culation hsis been inactive. Tlie rash has peculiar features ; it is of a dullish 
red color, and forms little crescentic or semilunar patches of variable size, affect- 
ed by the pressure of the finger, and separated by natural skin. The color 
also may be livid if the blood state is bad. The crescentic form is supposed 
to be due to the peculiarity in the distiibution of the cutaneous filaments 
of the nerves. The whole mucous surfaces are also affected, as may be seen 
in the palate, &c. 

Diagnosis, — The characteristic points are the crescentic form, with inter- 
vals of normal skin ; dull red color of eruption, which appears on the third 
or fourth day ; the presence of catarrh of the mucous surfaces, especially in 
the form of coi'yza. 

In scarlatina the color is bright red, and the rash is uniform, not cres- 
centic ; it appears also * on the second day ; the skin is very pimgent and 
dry ; there is sore throat, the tongue is raw at the tip, or slightly furred, 
with red points peeping through to the surface : there is no coryza. 

In Roseola the patches are scattered, circular in form, not made up of 
-crescentic portions, with intermediate healthy skin; the color is bright, 
and there is an entire absence of general symptoms, and coryza, <fec. 

SCARLATINA. 

On the second day of illness the rash appears on the neck and face, and is 
made up of small red dots, which crowd together, forming patclies of various 
sizes and extent ; after a while the whole surface becomes of an unifoiin hue ; 
on the third day, the eruption is seen on the body generally, the upper ex- 
tremities, and the mucous surfaces visible to the eye ; on the fom-th day, the 
lower limbs are scarlet, the sui-face is hot, dry, and harsh ; the eruption, 
which may be called a general efflorescence of boiled lobster color, is most 
marked on the third to the fourth day, and it is generally more intense in 
color towards evening, especially in the loins and flexures of joints. On 
the trunk it is often " patchy." It fades on the fifth day — first on the fleuje, 
desqimmation setting in about the eighth or ninth day. 

The diagnosis between scarlatina and rubeola is the only one that i*equires 
notice. 

In scarlatina the rash appears on the second day, in measles on the foui-th, 
after the first onset of symptoms. In scarlatina, the rash is bright red 
(boiled -lobster color) ; it is not crescentic, and it is uniform or not patchy, 
with intervals of normal integument. In rubeola, the rash is dull red, in 
little crescentic patches, wuth intermediate line& of healthy skin. The skin 
in scarlatina is very dry, harsh, and pungent. In measles this is not so 
marked, nor is the subsequent descjuamation so distinct and characteristic. 



ERYSIPELAS. 37 

In measles the changes in the mucous membranes are accompanied by secre- 
tion ; we have coryza, suffusion of conjunctivae — in scarlatina, the mucous 
surfaces are red, dry, ulcerated ; there is also sore throat of marked kind, — 
this is absent in rubeola. The aspect of the tongue is characteiistic in scar- 
latina, and the pulse is very rapid and irritable. 

ERYSIPELAS. 

Erysipelas belongs to the domain of the general physician, and to skin 
pathology only to a slight extent, in so far as the evidences of the blood 
and tissue alteration produced by its special poison are shown to the naked 
eye. It is an acute diffused inflammation, ushered in by constitutional symp- 
toms, and exhibiting itself locally by the presence of heat, tension, smarting 
or burning, over a sui-face disposed to vesicate ; with a tendency to spread 
rapidly in extent, with more or less implication of the subcutaneous cellular 
tissue and the formation of abscess or gangrene of the latter. Tlie constitu- 
tional symptoms are : a general feeling of illness ; depression ; rigors especial- 
ly, with alternate heats, thirst, quick pulse, loss of appetite, sometimes wan- 
deiing or delirium, nausea, with pain at the pit of the stomach ; and a white 
furred tongue, febrile urine, etc. It is usual to make two ty|)es of erysipelas. 
One in which the inflammatory action is sthenic, in which the general symp- 
toms are not gi'ave, and in which the structures, though perhaps extensively, 
are not very deeply implicated ; this is E. simplex. Tlie other, in which 
the general state is grave, the structures are deeply (and extensively) affect- 
ed ; abscess, sloughing, and gangrene are frequent ; the virus is of active 
quality and the blood state bad. This is E. phlegmonodes. The two divi- 
sional forms are merely degrees of one and the same state, chiefly influenced 
by two tilings — the quality of the virus and the state of the patient'^s health. 

A. — E. Simplex. — In this form of disease, the inflammatory action has 
its seat in the derma, and, perhaps, more or less of the cellular tissue be- 
neath. The general symptoms are those before described. The local symp- 
toms follow quickly or in two or three days, and commence as a burning 
or smarting sensation, followed by a feeling of tension ; the surface then 
looks puffy, dry, and slightly glazed, shining ; the edges of the patch look 
raised, the part is tender and hot. In two or three days, during which 
time the redness and swelling have increased, blebs may form, of various 
sizes and shapes ; these burst and dry into scabs ; in Ave, six, or seven days 
convalescence sets in, the local changes abate in severity, and a yellow stain 
is left behind, with more or less peeling off of the cuticle. Several sub- 
varieties have been described, according to seat, aspect, and character of 
course. Thus we have, — (a) E. erraticum, E. metastaticum ; (6) E. miliare, 
E. phlyctenodes, oedematodes ; (c) E. faciei, E. capitis, etc., etc. 

Lck'al Varieties. — ^Tlie most usual situation is the face (of course I am 
speaking of idiopathic erysipelas) ; it generally shows itself at the side of the 
nose, often at its root, quickly spreading, with great swelling of the parts, 
favored by the large amount of lax cellular tissue — e. (/., about the eyes, lips. 



38 EKY8IPELA8. 

cheeks, and ears. The disease may extend to the mucous surfaces. The con- 
stitutional symptoms are often marked by depression, delirium, restlessness, 
headache, etc. Erysipelas of the scalp is usually traumatic ; it may be slight 
or very extensive, the whole scalp may be undermined, puffy, and infiltrated 
by pus generally, or in the form of local abscess, the cellular tissue of the 
scalp sloughs, and the bone gets denuded and exposed ; and serious brain 
symptoms are often developed. 

Ei-y sipelas of the breast is common in lying-in hospitals, especially in women 
who are out of health, from, it is said, over-distention of the milk-ducts : 
this is probably only a predisponent. The breast looks red ; it is tender, hot, 
and swollen ; then feels bi-awny, pits on pressure, gives a good deal of pain, 
is accompanied by depression of the vital powers, and terminates mostly in 
abscess and sloughing of the cellular tissue ; the glands in the axillsB often 
participate in the disease. Erysipelas of the vulva often attacks the vulv» 
of lying-in women, especially primiparse. In children, erysipelas, commen- 
cing at the umbilicus, is often seen ; in hospitals particularly it leads to 
abscess and sloughing, and often de^th. When the scrotum is attacked, 
the swelling is sometimes enormous ; this is produced by the rapid pouring 
out of serum into the interstices of the cellular tissue. Some call it " acute 
inflammatory oedema," or, when it runs on quickly to the formation of pus, 
" acute purulent oedema." Erysipelas of the lower limbs is a fonn which 
betokens a bad state of general health, and demands active stimulant and 
tonic treatment. 

Erysipelas has been observed to disappear from one and make its appear- 
ance suddenly in two or more places in succession, or to " wander " over a 
large extent of surface; in such instances it has been styled erraticum. 
The disease is not very deep, but very obstinate of cure ; and often seasonal, 
or peiiodic. The face Ls its selective seat. 

£J, metastaticum speaks for itself. The mis<;hief falls upon some internal 
organ, coincident with the disappearance of the external blush. It is 
probable, however, that the gravity of the symptoms in such a case is due 
to the extension of the erysij>elas by direct continuity. 

jK mUiare and E, pltlyctenodes are degrees of one and the same aspect ; 
in the former, the blebs are small, in the latter large. Generally speaking, 
erysipelas presents buUse at the early period of its course ; they mostly give 
exit to a transparent fluid, and scabs form. In other instances, the disease 
is 2>eculiar in its great amount of swelling, due rather to a difference in the 
seat of the mischief ; for while the evidences of the implication of the skin 
are marked but slightly, the cellular tissue is noticed to be much more 
affected than in ordinary cases. The skin at the seat of disease pits 
easily on pressure (is oedematous), and preserves the impress made for a 
considerable time. This is the E. oMlenuUod^s of authors, and is met with 
especially on the lower limbs of debilitated persons ; it is also seen on 
the |>enis and scrotum. 

B. — £. Phleomonodes is, bo to speak, the inflammatory form. The 



OA.UBSS 07 EBTSIPBLAB. ' 



e&«ral Hymptoma of iuvasioD are sevi 
leliiium U uot I'are, ty]}1ioid syuiptoiut 
siderable danger, or death may ensue, 
ia the great rarity of the 



may 1 

^Kitth 

^^Kr he 

^^^■uid ni 
■ ^are mi 



re, fover rum high, rigora are sevoi 
often set in, and tbe patient is in a 
The characteristic of tbe local disi 
of rcaolutioQ. The ])art attai^ked it 
painful, hot, tunder, awollcn, very red ; in a day or two it becomes soflishj 
rigors and throbbing pain anno\ince the occuireuce of auppunition, whie 
may be very extensive ; tbo celhilftr tiasiie, the faeciie, the inteminsciila 
Mpta, all partake in tbe diseased action ; the blusli has gone, or nearly a 
^t the swelling has increased. The contiuned pus is mostly mixed "k 
wd and portions of cellular tissue. lit this variety, a cliange takes ploc 
r better or fur worse about the Sftli or sixth day. In ar 
^ere the virue ia of bud quality, or the patient'a health ia markedly bad 
I sloughing and destruction of the cellular tissue mtiy be exteiisiTi 
ind marked : this is the E. ijangrKnomm. The constitutional symptomi 
are markedly severe, the inflamed part becomes dark eoloi-ed, blebs a|>|>eai 
filled with bloody fluid, tbe general aspect of the Umb is ecchyniotio, msii 

I it feela tense at firet, then boggy, puffy, and at length gives way ; dirty mat 
In exudes, tbe struutui'es slough, the fasoiis and cellular tissuo moctify, i 
Iw patient sinks, or recovers with greiit difficulty, the local miacbief ti 
P the powers ta their utmost for the |irocess of rejiair. 
m Cautes. — Varioua causes have been assigned to erysipelas ; all we knm 
■ this, that it is due to a special poison, which attacks those whose resistant^ 
lower b weakened either by mental or bodily ailment. It attacks « 
bore than men in the projmrtion of about 7 to 4 ; though it is less fatal t 
Be former, in women, too, the disease is mostly idiopathic. The death-ii 
K 2flO cases, given by M.r. Bii-d, was 7~5 per cent. The average duratiot 
of cases is from ten to twelve days. It occurs mostly in spring and autnnmd 
it is eapecially liable to occur in spirit-drinkei-a ; those reaident iii hospitalaa 
if wound. There does not appear to be any oonnection between tl 
e of erysipelas and derangement of menstruation. It lias its nuudiJ 
a degree of frequency about the age of twenty, gradually decreasing tiu 
hit of thirty.five (Aubi-ee). Cold aud moisture together are regordeil i 
[TOriug its occurrence ; and, on the whole, traumatic ia moiv fatal than idi^ 
Mthic erysipelas. It appears that Blight's disease especially favol'S tbe a 

e of erysipelas if any tmumotie injury be received, 
I JKaffnimit. — ErysijKtlas can scarcely be confounded vdth any disease, withi 
3 exception of erythema ; but the general symptoms, the tense, sliiuingpfl 
; blush, and the implication of the cellular tissue, are not observM 
^ eiythemo, 

' The J\ngnoitU. — The case is grave if the genei'al symptoms intlicate hig 
', with subsequent pitistration ; if the patient be old ; if it oc 
r limbs ; if it be seated at tjie scalp ; if there be iliffuse abscess with 
jpresston ; if the surface assume a livid aspect., and present phlycteme ; 
fcfipe be much vomiting and deliiiimi; if it be phlegmonous variety, i 
lebitJA ensue, and if it be metastatic or erratic, 



40 EQUINIA. 

Treatment, — In treating erysipelas, we must always look ahead, and cal- 
culate, to the best of our ability, the probable amount of depression that 
will be produced by the virus action and the formation of abscess, and the 
amount of demand that will be made by the reparative process. And we 
can often do this. If rigors are severe, if there be high fever, and if the 
local symptoms are equally marked, then not only will the present excita- 
tion produce a marked subsequent diminution of vital power, but nbscess 
and destruction of tissue will probably be more or less extensive. Then if 
the patient be out of health, if he be surrounded by bad hygiene, and 
especially if he be of good or advanced age, we must husband all the power 
he possesses. The pyrexia is treated upon ordinaiy principles ; only am- 
monia should enter into the composition of our saline mixtures. A brisk 
purge is required at the outset. 

Now should the disease be severe, we should be on the qui vive for the 
first symptom of failing power, and treat the disease as tending to produce 
acutely a typhoid condition. Common sense is our guide in regai'd to diet, 
wine, and medicine. Where the disease is less severe, sulphate of magnesia 
and quinine, or, what is better, tincture of steel, in large and frequently 
repeated doses, is the remedy I employ: iT^xx — TTixxx — 3 i. every hour. 
Locally, we exclude cold, apply heat, and keep the part covered up. In the 
early stage, practise inunction of lard subsequently to painting the part with 
a solution of nitrate of silver in spirit of nitric ether ; or if there be much 
pain, api)ly warm lead, belladonna, or poppy fomentations. In all cases 
early excision in suppuration, and for the relief of tension, is essential. 

EQUINIA, OR GLANDERS. 

^qulnia, or, as it is usually called. Glanders^ is a disease which originates 
in the hoi*se, the mule, and the ass ; and when it occurs in man it Ls com- 
municated to bim from one or other of these animals, either by the contact 
of the " discharge " of the disease with wounds, or by pure absorption. In 
the former case glanders commences as an erysipelatous inflammation of the 
lymphatics and glands, following quickly upon the poLsoning of the wound. 
In other cases there is a period of incubation of from thi*ee to fifteen days. 
However, the introduction of this poison into the human subject is followed 
by the development of acute febrile symptoms, rigors, articular pains, 
delirium, marked prostration, with a tendency to gangrenous inflammation 
of the lymphatic vessels, the occurrence of a pustular and j)hlyctenular erup- 
tion, inflammation of the skin, ulceration and discharge from the nostrils, 
with subcutaneous abscesses. The above is a rough outline of the disease. 
Veterinaiians describe two varieties of equinia, Glamhrs and Farcy, In 
the former the disease falls upon the nasal mucous raembi*ane and the skin ; 
in the latter the nose is unatTected, and the skin often escapes ; the lympha- 
tics and glands are specially the seat of disease. Glanders may be Sicxxte or 
chrome. In the acute form there is inflammation of the lymphatics, with 
abscesses specially about the face and over the joints. Pustules appear over 



DENGUE. 41 

the che^k, the arms, and the thighs, and commence as red papules, with a 
distinct areola, isolated or semi-confiueiit ; these are accompanied by bullae 
with dark areolse. At the same time there comes on what appears to be 
erysipelatous inflammation of the nose, eyes, and the contiguous parts ; and 
soon from the nose a thick, viscid, often foetid humor is discharged, and if 
the nasal mucous membrane be examined, pustules and ulceration will be 
observed over its area. In the chronic disease the skin may be free from 
eruption, but the nasal symptoms are present. The general symptoms are 
the same as in the acute variety, only less marked. 

Farcy is either acute or chronic. In acaie farcy all the general pyrexial 
symptoms of acute glanders ai*e present, and occasionally some eruption oc- 
cura, but the nose escapes. The disease may therefore be regarded the same 
as acute glanders without the nasal affection. Inflammation of the lympha- 
tics and subcutaneous abscess are prominently marked. In chronic farcy 
the health deteriorates, and chronic indolent abscesses form about the fore- 
head, the calves, &c., giving rise to open ulcers. The disease lasts from a 
few months to three years. Acute glandei*s may be developed out of chronic 
farcy. 

Diagnosis, — The disease commences like rheumatism, but the occupation 
of the attacked, the commencement of the disease like erysipelas, the pros- 
tration, the absence of joint inflammation itself, the pustular eruption, and 
the ulceration and discharge from the nose are significant. In chronic glan- 
ders there may be no eruption, the disease then resembles oza^na, but if 
farcy be present the diagnosis is certain. With regard to farcy, if eruption 
be present, no mistake can occur, but difficulties do arise in chronic farcy 
without eruption. We determine the nature of the case by exclusion. It 
may resemble syphilis. 

Frognosis, — Equinia is a dangerous disease, and in acute cases almost 
always fatal. 

Treatment, — I have no experience upon this point. It has never fallen 
to my lot to treat a case of glanders. We are told upon good authority 
that the combination of ai-senic and strychnine acts apparently better than 
anything else. Hyposulphites, and perchloride of iron, have been recom- 
mended. The use of nitrate of silver to the eruption, and chloride of zinc 
solution, two grains to an ounce night and morning, to the nasal mucous 
membrane, or a weak carbolic acid lotion, is commended. 

DENGUE, OR DANDY FEVER. 

In East Indies, Calcutta, and West Indies, a disease called Dengue exists. 
About the third day the skin gets turgid, and an eflloresccnce, beginning at 
the palms of the hands, gradually spreads over the entire body ; it is not 
unlike in some cases measles or scarlatina, of a blotchy aspect. The rash 
may be raised, and feel rough. There is often tingling, that may increase 
to most intolerable itching ; in some cases distinct local swellings may be 
present. The rash begins to fade on the second and disappears on the third 



42 FBAMBCESIA. 

day, being followed by some desquamation. One case is recorded in which 
an old man " peeled off" in scales, like pieces of parclmient, leaving the 
skin behind quite red : in some cases subcutaneous abscesses form. Hence 
there is eiythematous redness invading the whole body, beginning at the 
hands, accompanied by swelling, and followed by desquamation like scarlet 
fever. 

Dr. Furlonge described the disease as like measles, with papules and 
wheals, as a cross between rubeola and urticaria.* Dr. Mellis described it 
as a roseola or lichen simplex. Dr. Mouat as erythema papulatum, or pur- 
pura simplex, but disappearing on pressure, and in other cases as like rose- 
ola or lichen tropicus. 

RUBELLA, RUBEOLA NOTHA, BASTARD MEASLES, ANOMALOUS EXANTHEM. 

There is a form of eruption which resembles measles, but differs in sevQ- 
ral particulars, and about which much dispute exists. It was described by 
Dr. Babington under the term Kubeola notha ; it is thought by others to be 
a Boseola. In some instances it seems to have a bright red punctated 
aspect, or is not unlike scarlatina. This is probably Hardy's erythema 
Bcarlatiniforme ; Dr. Kichardson has called it rosalia. It is common iu 
Egypt, I know; it is reported as having occurred at Malta, India, <S:c. 
After more or less pyrexia, a dusky red papular rash appears. It is never 
crescentic, but is unifonnly distributed. The redness, the hue of which 
may vary, is most intense during the first day, when the rash is seen on 
the face, arms, legs, body, in succession ; there may be slight desquamation. 
There are no catarrhaFsymptoms, though the fauces are reddened. The pa- 
tient very quickly rccovei-s, there is no dropsy or renal disease following in 
its wake. It is not contagious, and it often occurs in those who have al- 
ready had measles. In one sense it is a satisfactory disease — it i*equires no 
treatment. It is difficult sometimes to say to which the eruption is most 
allied in aspect, rubeola or scarlatina, but in either and all cases there is an 
entire absence of the general features of these diseases. It is scarcely 
bright enough in color for a roseola, though it might very well be regarded 
as a roseola of dark color. 

I append a note on 

FRAMBOESIA. 

t 

Framhcesiay called also mycosis, pian, or yaws, occurs in America, Guinea, 
the West Indies. Opinions differ as to its nature, and I do not know 
where exactly to place it. It is said to be an exanthem. The disease com- 
mences with general debility, languor, and pains simulating rheumatism ; 
then about various parts of the body, especially the face, axillae and genitals, 
arms, and rarely the scalp : little red spots appear — generally moi-e or less 
grou|)ed — they have been* described as resembling flea-bites, which quickly 



• ** Ed. Med, and Suig. Joum.," p. 52, 1830. 



FBAMB(£6IA. 43 

become papular : or ratlier at cei-tain spots little reddish elevations appear, 
which in tlie course of a few days become quasi-pustular, give exit to a lit- 
tle ichor, and then become covered over by dry and adherent scales. The 
skin around is dry and harsh. The disease now makes progi^ess towards 
the formation of distinct tubercular elevations, and in two or three months 
the exact resemblance to a mulberiy is produced : there is no pain, and suc- 
cessive crops of tubercles occur from time to time; so that the disease 
covers over a surface of variable extent. Tlie little tubercular i)rojections 
are united together at thei\* base, and are free at the apex, and one of them 
becomes considei-ably more developed than the rest, so as to fonn a distinct 
projection like a nipple : this is called mama, or mother-yaw ; it presently 
ulcerates, and then appears as a foul ulcer, giving exit to an offensive ichor. 
Various attempts at repair take place, as evidenced by the many cicatrices 
present. The disease may last for years : it is said to be inoculablo by 
means of the ichorous discharge ; it often gets well, but may exhaust the 
patient. It occurs but once in a lifetime, attacks young i)eoi)le by prefer- 
ence, and seems to be produced by social and hygienic mal-conditions identi- 
cal with those of le]>rosy. It attacks black more than white peo2)le : it has 
no relation to syphilis. 



CHAPTER VII. 

ERYTHEMATOUS DISEASES. 

• 

The diseases -which rank under this head are exceeding simple and well 
defined. They are three : erythema, roseola, and urticaria. Willan placed 
these with the acute specific diseases, under the term exanthemata, but though 
pyi*exial, and the result, as regards the eruption, of a disturbance of the normal 
state of blood, yet they do not run so definite a course ; they do not depend 
upon so specific a cause in each case, and they are not contagious, hence they 
form a separate group. They are characterized mainly by the occurrence of 
active hyperajmia of the longitudinal plexus of the skin (erythema), and its 
immediate consequences — nothing more. In other diseases hypcnemia is 
present, but then it is the insignificant element in the morbid processes ; the 
squamation, the exudation of serosity, the formation of crusts, the hyper- 
trophy of the papillse, the morbid cell-growth, all indicate peculiar altera- 
tions in the behavior of the tissues, which cannot be explained by the 
presence or as consequences of hypersemia. In erythematous diseases the 
redness is rosy (roseola), or bright red (erythema and urticaria) : in the 
latter "wheals" are present. The erythema is removable by pressure. 
Unlike the more common eruptive diseases of the skin, the erythemata 
exhibit the closest connection between local and constitutional phenomena. 
Febrile symptoms antecede and are relieved by the development of the ery- 
thema, showing that the local skin-changes are secondary, and only parts of 
a general disturbance, which is primary. These remarks apply generally to 
the three erythematous diseases, but there are one or two rednesses produced 
by local irritation wliich it is customary to include under the tei*m erythema. 
In many of these cases there is a predisposition to hj-perromia in consequence 
of digestive disorder. Erythema of couree occurs as part of many diseases. 
I refer now to those forms which constitute independent diseases. 

I. erythema. 

This disease is a superficial inflammation of the skin, occurring in slightly 
raised patches, diffused or circumscribed, of varying size, rarely exceeding, 
however, three or four inches, and generally much less. The redness dis- 
ap]>ears at once by the pressure of the finger, but returns instantly on its 
removal ; it is accompanied by slight swelling, simulating papulation or 
slight tuberculation from exudation : heat: and itching : and ends in fiirfu- 
raceous desquamation with slight staining. The general svmptoms are 
slight : t. €. mild fever, headache, quick pulse ; they may be nil. 

The varieties of this erythema eruption may be divided into two gioups : 



45 

A, local or idiopathic ; and B, sTmptomatic. In the former the disease is 
merely hyperaemia, without much, if any, appreciable elusion into the cutis 
and cellular tissue ; in the other there is more or le«s escape of serosity fix>m 
the vessels, and hence prominence of eruption. Hence the two groups have 
been designated respectively after Hebra, eri/thema hypenfmtcitm and ery- 
thema exgudiUivtim, 

Group L — Idiopathic, local, or hypenemic : includes eri/tJtema « wi/>/«r, £ 
intertrigo^ E. Ictve, EIrythema simplex is produced by the irritation of 
external agencies, friction, stings, heat, the contact of acrid fluids, plasters, 
medicinal inunctions, and stimulating applications of all kinds. There is 
redness, diminished or dissipated by pressure, returning on the removal of 
the finger, with no sensible swelling, but a sense of heat, and variation in 
color according to the activity of the general circulation. Wlien producetl 
by external injury, it is said to be traumatic. The slightest forms of bums 
would rank under this term. Chilblains, or pernio, is another form of ery- 
thema caused by cold. Erythema intertrigo^ or simply intertrigo, is the 
name given to the redness which is produced by the friction of two folds of 
delicate skin, especially in fat persons and children : this is seen in the gi-oin, 
axilla, neck ; sometimes the irritation set up causes the exudation of a fluid, 
partly perspii*ation, whose acridity increases the local mLschief, and i)i-eKently 
an ofiensive raw surface is produced, giving out a mucifomi or purifomi 
fluid (the erythema purifluens of Devergie). Tlie some disease is »et*u about 
the prepuce and the vulva. Intertrigo is particularly seen in lymphatic 
subjects. It simulates eczema ; but the origin is evidently from the friction 
of two surfaces ; the secretion is not that of eczema — it is thin, niuciforni, 
stains but does not stiffen linen. Hai-dy correctly describes the disease pro- 
duced by the inunction of mercurial ointment, as a vesiculo-pustular ery- 
thema; in which, upon red patches, little vesicles (or puriform vesicles) 
appear, quickly rupture, desiccate, leaving behind an erythema, whose sur- 
fleioe desquamates : the disease subsides in a week or ten days. It differs 
from eczema in its acute course, and the character of its secretion, which is 
clear, not viscid, and does not stiffen linen, as in eczema. 

E. UjBvej is the name given to a blush of erythema, of greater or less extent, 
which is seen over oedematous parts, especially on the front of tho legs in 
dropsy. The skin may slough and become gangrenous at the seat of tho 
blush. The redness which precedes the formation of bed soi-es, rt*ceives tho 
name of erythema pa/ralrimma. It is caused by the i)rcssure of cousttuit 
lying when the system has lost much of its tone, as in fevei*s and other low- 
ering diseases. Hoblyn, in his dictidhary, says paratrimnia is a " 8])ecies of 
erythema or cutaneous inflammation, produced by friction in riding or 
walking.'' 

There are certain local forms of passive erythema produced by mechanical 
obstruction to the passage of the blood through the veins, by tumors, 
ligatures, gravitation, inaction of the heart, varicose veins, and the like. 
In titose cases the color of the redness is bluish, or dark ; the erythema is 



46 EEYTHEMA. 

removed by pressure, but tardily returns, and the part is often sensibly 
cold and swollen. 

Group II., or Symptomatic. — Under this head rank those hyperssmias 
which are the consequence of a more or less general pyi^oxial state. In all 
of them there is malaise, headache, and quick pulse, pains about the joints, 
and disordered bowels, a day or two before the eruption appears, which as- 
sumes different forms, and Hebra has included all these under the one term 
erythema multifoime. In England we specify JE, papulatum^ tuberctdatum^ 
nodosum, fugaxc, imirginatum, and circinatum. The first three of these 
are stages, the one of the other, and during their course the redness assumes 
a bluish tint, and fades away insensibly into the surrounding skin. In ^. 
papulatuin, small red spots, varying in size from a pin's head to a split 
pea, appear ; at first they are not raised, but presently become papular, of 
more vivid color, pale on pressure, and die away in a few days with slight 
desquamation. These spots may be aggregated or separated, and are seen 
especially on the back of the hand, the arm, neck, and breast. The disease 
lasts about three weeks, and seems to be associated with rheumatic symp- 
toms. It occurs mainly .in young people. E, ivhercidatum is the same 
disease, in which the erythema becomes somewhat tuberculated. It is seen 
in servants who make a change of residence from country to town. E, 
nodosilin is a more marked stage of the last noticed ; the spots are larger — 
as large as a nut or walnut, even attaining a diameter of two or three inches, 
the long diameter being in a majority of cases parallel to that of the limb, 
oval ; they are generally seated on the anterior aspect of the leg, rarely on 
tlie arm, or above the knee. The swelling is raised, slightly hard, painful, 
and evidently accompanied by tumefaction of the cellular tissue ; the red- 
ness, at first vivid, but not so defined or limited as in E. papulatum, pre- 
sently becomes purplish at the circumference and paler in the central part, 
dying away like an ecchymosis. Tlie patch also softens and often simulates 
fluctuation, but it is said never aupjyurcUea, Chorea and rheumatism are 
associates. It is uncommon after the age of twenty, and appears to be 
connected in some way with adolescence. It is generally accompanied by 
pyrexia and rheumatic pains. Dr. Durkee, under the head of E. tubercula- 
tum et oedematosum, has described a disease consisting of little tubercular 
elevations, vesicating at their apices, then flattening, the skin meanwhile 
showing a " shrivelled or collapsed condition of cuticle." The E. exoentri* 
cum of Biett is lupus ery thematodes. 

Hie swellings in these vaiieties of erythema are due to effiision of simple 
serosity into the corium and cellular tissue of the skin. JS, fugax is simply 
patchy-redness, which quickly disappears, and is capricious in its character. 
Tliis variety of erj'thema is noticed in persons of irritable habit, in those who 
are suffeiing from any digestive or assimilative derangement (especially in 
females) — e, </., from dyspepsia, muco-enteritis, uterine, hepatic, or renal dis- 
ease of sub-acute character. The erythematous patch is red, but tender, 
fading, and desquamating, and accompanied by more or less pyrexia. 



EBTTHEMA oangbsnosth. 



47 



' Should the lilusli be circular witli an unaffected centre, it is called E. cir- 

cinAluiu ; and if it have a well-dafined circunifereDce, E. mai^natuin. I 

aliould imagine that theue two latter were often the erythematous Btngcs of 

piiraaitic tiisease, tinea circinata, attd esjiecially in hot aeaitons, of chloaBina. 

I 2lKrdy deecnbes an erythema scartatiuifoi-me that hae been referred to undto' 

a head of rubella or anomalous exanthein, 

. Acute diseases, especially at the time of convalescence, of^n exliibit a 

' sUglit access of febrile disturbance, find after a little itching and loctil heat, 

red patcheB appear about the Hmbu, thighs, the buttocks, the neck, and 

fiice. They vary in mm from that of a pea to that of the palift of the hand. 

r They are vivid red, last a few days, ami theu fade witli deaipianiation, Thia 

'b fr^uently ail accomjianimeut of thrui>h. Hyoscyamus, belladonna, luid 

Ipaiba give rise to erytheuiata, noticed iiuder the head of medicinal rashes, 

d Uatiy, after auigical oporationa red rashes occur : these are generally 

wlouB ; tliey may be eiysipelatoUB or indicative of pyreraia. 

?rt/(A«ma Gnnffmnotam. — In persons who are reduced by debilitating 

Bd, patches of dull erythema may occur here and thei-e, and instead of 

the reparative pvocens being properly canied on, the jiart may slough 

und become gaugrenons. Tliis one readily understmids. Xa muny cases 

INttches of purpura are the Btaiiing-jioints of the gangrene. Mr. Wilson 

ie in which calcareous Bolidificstion of the ai'teries was found 

death. The afection haa been named erythema gangrtenoaum. in 

s Hospital there are models of it. Dr. Morley Itookc, in WSi, descrlb- ' 

II which ho believed it occurreil. ISut I think it is different in 

t from true gangrenous erythema ; the case is worth mentioning. The 

a lady, unmanied, good-looking, and hysterical, of general good 

Alth, with vivacious manners, and aged thirty-nine. AfLer an attack of 

» and hystei*ia, she began tO' betray veiy capricious tastes and 

mpen towards everybody with whom she had to associate, Ou the fourth 

V ft small red patch apjieared below the left mamma, in the sulcuB be- 

n it and the ribs, IJ inch by 1 inch in size. The patch was not elevatr 

I, but tliere was some pricking Bensation in it. For two or tliree days 

8 remained in statu quo^ then suddenly a good deal of redness ovet^ 

tul ti Wge part of the mamma, and in the course of the following day, 

e patch the size of a shilling, flnt, Bmonth, painless, was observed in 

e centre of the blush, and in the nex.t twenty-six hours ihiB had enlarged. 

e size of half an orange, the cuticle having become loosened at one l>art, 

1 the skill beneath as whit« aa, and about the color and a]>pcaraiice of, 

(BUOOCh layer of firm wax or tallow (being insensible and dead). No buUn 

r vesication occurred. Patches next appeared is. symmetrical order over 

t parts of the body for four months : after a time irritation of tlie 

oeys and bladder set in, i^. Now this form of disease was wholly dif- 

ait from true gangi-ene of the skin. There was, in tlie first place, an en- 

; of any general enfeebling condition sufQcient to account in 

J d^ree for the occurrence locally of gangrene — nay, the patient was 



48 



ACBODTNIA. 



stoiit, Wtrll iiourislieJ, and of good Itenlth. The erythema, at ha first oonur- 
renue, was bji active one; it wna of giioil color; the reiiaralive process waa 
active. The eoexistenoe of giin^retie due to a general lowering of vitality, 
and of activity in the locul circuUtion with rapid repair, involve a manifest 
Oonti'ftdiction the one of the other. On this gnmnd aloue I deny that th« 
alTection was produced naturally. Then, od the other hand, suppression^ 
not merely retention, of urine appetired in three weeks, together with oyeU- 
tis, aevere vomiting, Jic— 'Symptoma at once referable to the absorjition of 
cniitharides, and its action ii|)0u the urinary organs : hence tlie bloody nrine. 
In addition, the patches of disenae sometimes only reddened, and did not 
ulough. Tlieu Ilia rapid destruction of tissue, the general syniptoua bearing 
no sort of relation to (wholly unacoounting for) such kind of destruction; 
the evident attempt to conceal tlie early erythematous stage of disease ; the 
healthy healing of the sove ; the non~BSBttmption by the bed~sore of thfl 
characttira of ulcers elsuwliere (i^ufiposLng the blood to be under the ioflu- 
enee of a apecial poison) ; the period of i-epose aesumod by the disease, its 
long ooui'se, the moist aspect of the slough (being quita different from that 
produced by blood-|>oiso]ii]ig, and exactly that produced by local applica- 
tions) and the marked hysteria of the patient ; all point to an artificially- 
produced distiase, and so I feel sure it wan. When erythema is followed by 
gangrene, there must he a siitKcieut lowering of vitality to account for local 
death, which is immediately induced by purpurce, by embolism, or by ob- 
8trncte<l arteiies (calcareous or otherwise). 

ACRDDVNIA. 

[Under this name is described an epidemic form of erythema which oc- 
cnrred in I'aris in 1828-9, Tlie disease wan only the manifestation of Bome , 
general blood state. The general aymptonts were pains, malaise, anorexia, 
febi-ilo movement, vomiting, diarrhiea, swelling of the face, and injection of 
the eyes, with the develo[>ment locally, especially about the hands and feet 
(the palmar snil plantar aspects), of vivid red patches of erythema, ex- 
tending sometimes to the arms unil legs ; the color presently changed to a 
very dark ecchymotic hne, aiid extended, more ov leas generally, ov«r th« 
body, nock, and face. The ejiidermis peeled off in flakes ; fVmmcles, papulea, 
puatules, and bullin sometimes forming ; a discharge took place and dried into 
thick omsta ; a good deal of j>ain and swelling accompanied these chauges, 
with a cei-tain degree of numbness of the limbs. The symptoms varied 
somewhat In different oases. Rctierally the diaiMse became chronic, lasting 
several woeks or months ; and frequently recurred. It ap|>eare(l to be fa- 
vored by a bad state of the general lienlth, and Chomel thought it wae 
caused by eating diseased giiiiii. In pellngra a aimihtr dark erjthema ia 
brought out by the action of the sun. I have seen also, on several occa- 
sions, a s|iecies of erythema which is not d<.'Hcril>ed in books that I am 
aware of. It occurs especially about the back and sides of the hands and 
fiugcn iu thoae vut of health. The skin becomes red, in little circular 



ERYTHEMA. 49 

spots, from which the epideiinis peels off by a centrifugal death, as it were, 
leaving behind a red dry siii-face, marked by circular ridges of wliat appear 
to be normal papilhe. Tlie places are many ; the disease is chronic, and re- 
quires no treatment. It looks simply like the death of the epidermis, be- 
neath which is seen the reddened derma marked by circulai* ridges of prom- 
inent papillae. It is not erythema circinatum ; it is more like a superficial 
acrodynia.] 

PrognoaU of eiythema. Erythema when it becomes chronic Ls a source 
of great discomfort ; in the more marked forms the disease lasts two or 
three weeks. In E. lieve and E. pai*atrimma, the prognosis is that of the 
general malady j)resent. 

Diagnosis. — £rytheina is known by its superficicd charact^^r' the redness 
disappearing by pressure ; by the peculiar change in the color of the cir- 
cumference of the patch from bright red to purple, the absence of marked 
itching, heat or tension, or burning, its general circumscription, little ten- 
dency to spread, patchiness, but slight elevation. Knjsipdas differs in the 
shiny, hot, burning, tense, blushy swelling, the rigoi-s at the onset, the ten- 
dency to sj)read, and the implication of the cellular tissue, the deep (non- 
rosy) hue. Urticaria is known from erythema by the peculiar stinging 
sensation; the presence of wheals, which go and come in a wondrously 
capricious and sudden manner ; by the irritability of the skin, (jiisily de- 
tected with the nail or slight friction. Roseola is something like E. papu- 
latum, but the general symptoms are esj)ecially pyrexial in the former, 
rheumatic leather in the latter ; the eruption of roseola is rosy or pink and 
of a defined character, often punctate : erythema is genonilly a i)artiid, 
not a general aifection like roseola ; the latter often assumes tlie aspect of 
measles (false measles). E. marginatum and circinatum are said to be dis- 
tinguished (especially the latter) from herpes circinatus by the presence of 
vesicles in the latter, in which the erythema is very transient, and fui-fu- 
raoeous desquamation subsequent to actual or abortive formation of vesicles, 
very distinct, but the diagnosis can only be settled by the microscope. E. 
liBve and E. fugax speak for themselves, the former being associated with 
dropsy. E. papulatum may resemble licJien urticatus; but in the latter the 
papules entirely put into the background the slight erythema; the papules 
are large and often piiiriginous ; the skin is irritable, with a sense of heat 
and stinging ; and a tendency to the formation of wheals is apparent. The 
skin generally is dry and harah. E. papulatum assumes a bluish tint after 
a few days; it is seen on the back of the hands, arms, and neck especially, — 
not on the body so much as lichen ui*ticatus, and it is not truly papular ab 
oritjine, E. tuberculatum and E. nodosum can scarcely be mistaken ; the 
oval, tense, red, subsequently softish feel, pale centre, and livid circumfer- 
ence, are absolutely distinctive of the latter. Krythema is, of course, a 
dry disease, and, except in the form of intertrigo, does not resemble ecze- 
ma; but the latter is essnntip.liy a vesicular d^se^isc., ftn^I i£s.isVoretion is 

viscid, stiffens linen, dries into distinct yellow crusts. Licoiirigo is ol- 

4 



50 ROSEOLA. 

served to be produced by the friction of folds of skin in fat subjects, and 
possesses no ci'usts, and only thin muciform discharge. 

TreatmetiL — In the local erythemata we must fii-st reniove all irritants, 
pay especial attention to cleanliness, and merely apply soothing agencies — 
e. r/.y to prevent dryness or friction, <fec., zinc ointment, or glycerine and 
rose-water: liniment, aquas* calcis ; fine starch, or lycopodium powders; 
avoid poultices, and give aperients internally. In intei-trigo we adopt the 
same plan of treatment in mild cases. Sometimes it becomes a troublesome 
disease, with sour acrid discharge inducing even excoriation ; this generally 
depends upon some internal derangement, whose type is muco-enteritis. 
In these cases, alteratives with chlorate of potash, in the first instance in- 
ternally, are of service, particular attention being paid to diet ; such food 
as corn-flour, maizena, and the like, must be forbidden, and proper nutritive 
substitutes (Hard's food) employed in conjunction with a suitable quantity 
of milk. Tlien locally, zinc ointment, starch powder, bismuth lotion, weak 
zinc lotions, the calamine lotion, given in the formulary, and lastly, if 
chronic, weak solution of nitrate of silver may be used ; syrup of iodide of 
iron and cod-liver oil are also called for. * 

In the erythemata dependent upon general causes we have to remember 
the effect of ingesta ; that a gouty or rheumatic habit, disordered menstrual 
function, dentition, delicacy of skin, or lymphatic temperament, arc present 
in gi'eater or less degree. "We are careful to give an unstimulating diet, to 
forbid spirits, wine, and beer, to clear out the bowels, and in the early stage 
to adopt a saline regime, and tepid sponging, with emollient baths. Tonics 
are generally demanded ; if there be any distinct rheumatic symptoms, we 
must increase the renal secretions, get the liver to act by aperients, and 
then give colchicum (in acute cases) and iodide or bromide of potiussium 
with bark. In E. nodosum, aloes and iron in combination are very useful 
in the fat, bloated, full-colored, but flabby and stunted lymphatic subjects, 
that arc oft^n affected. Locally, the use of an alkaline lotion is all that is 
needed. 

In all cases, if there appear to be an overloaded yet ansemiated state of 
system, we may combine (saline) aperients with preparations of iron ; and 
any neuralgic tendency is met with quinine. 

Bed-sores are best treated by attempting to " harden " the skin in the 
early state by spirit applications, removing pressure as m\ich as possible ; in 
latter stages by pads, cushions, and w^ater-beds ; and using charcoal poul- 
tices or soap plaster spread on soft leather to the sores. For chilblains, 
equal parts of tuq)entine and tincture of acomte or belladonna, and soap 
liniment, together with tonic treatment, iron, quinine, and cod-liver oil, is 
t)ie 1>est treatment. 

II. ROSEOLA. 

It is i in tvoHwl^ ^-JuiQit th^s di^cjak^; ci^t. so much because it gives rise to 
any anxiety or trouble, as that it is likely to be confounded with measles and 



IDIOPATHIC GROUP. 51 

scarlet fever. The disease is characterized by its being non-contagious, 
more or less febrile, and giving rise to the development of a rash, not much 
raised above the level of the surrounding part, and of rose color. The 
eruption is patchy, and its color deepens somewhat as the disease advances. 
It is accompanied by slight itching and sensation of heat. It is not [)re- 
ceded by any marked signs or symptoms of catarrh, but only slight redness 
of the mucous surfaces of the palate and fauces. 

Roseola is divisible into two groups : Jffiopntliic — R. infantilis, a^stiva, 
autumnalis, annulata, punctata. ISynijHomatic — R. variolosa, vaccinia, 
miliaris, rheumatica, arthrica, cholerica, febris continue. We see, there- 
fore, that roseola is wont to occur as an accidental phenomenon in the 
course of acute diseases, where it is called symptomatic ; in other cases, it 
is the sole and primary disease. 

Idiopathic Group. — Roseola infantilis is seen in infants, and resembles 
measles ; it nms an in*egular course as regards precursory symptoms (which 
vary in degree;, and in the extent, degree, and seat of eruption. Now, it 
is pretty general but patchy, now, limited to the arm, or the neck, or trunk ; 
the rose-blushes often come and go for several days capriciously, and are 
accompanied by local heat and itching, which are often marked at night. 
The catarrhal symptoms of measles are absent. The patches are about 
half an inch or so in diameter. Tlie redness generally lasts a dozen or more 
hours. /?. asstiva appeara, as its name signifies, in the summer-time : after 
slight pyrexia and much local itching, the rose-rash appears on the face, 
neck, arms, travelling thence over the body ; the mucous surfaces are 
affected, and the disease may put on the aspect of scarlet fever ; the i*ash is 
unattended by desquamation on disappearance (about the third or fourth 
day), but leaves a darkish stain. Sometimes the rash is very uncertain and 
irregular in occurrence, and then the disease is prolonged in duration. It 
may be partial oidy, but always has the roseate hue. The very same erup- 
tion occurs in the autumn, generally in children, on the arms and legs, in 
the form of circular blushes, about half an inch in diameter, but of a dark 
hue. This is the JR, autumiudis. When the disease assumes the form of 
rings (and this is genei*ally observed about the buttocks, thighs, and 
abdomen), developed from little rose spots, and enclosing pi*esently a healthy 
circle of skin, an inch or so in diameter, the variety R. aimulata is present. 
The concomitant symptoms are the same as those of the R. jestiva. !Mr. 
Wilson describes a variety under the term R. punctata, in consequence of 
the punctated aspect of the rash. It appears to be pretty general, with 
slight fever and catarrhal symptoms. 

The Symptomatic Group contains specicjs which are merely rosy 
eiythemata developed in the course of acute diseases, generally appearing 
about the arms, breast, and face, thence spreading over the body. H, vac- 
cinia coexists with the formation of the vaccine vesicle, and is accompanied 
by slight fever. It commences around and about the seat of the vaccina- 
tion. In cases of fevers, about the tenth day or so, and indeed whenever 



52 ROSEOLA CHOLERICA. 

tlie weather is hot or perspiration free, a number of niinute scattered 
vesicles are likely to be developed about the clavicles, chest, and neck; this 
is miliaria. It is often accompanied by a rosy blush, to which the name 
a. milmris has been given. It is the J?, fehrilis of authors. Some further 
remarks in reference to miliaria will be found under the head of diseases of 
the perspiratory glands. So in acute rheumatism and gout, the rose rash 
has been teimed li. rheiirtuitica. 

Roseola clu>lerica (Rayer). Tlie changes which the cutaneous circula- 
tion undergoes in cholera, predispose, as might naturally be expected, to 
the occurrence of eruption, esj^ecially duiing the stage of reaction, which 
vanes very considerably in different instances. The eruption may be a 
roseola (Rayer, Babington, and Romberg), and is then seen about the 
hands, ai*ms, neck, breast, abdomen, and limbs ; in other instances, the so- 
called exanthem of cholera is a " pustular redness," or miliaria, or herpes 
zoster, or E. tuberosum, or presents the aspect of urticaiia. It is more 
fi*equent in males than females. 

After surgical oj^erations a rash like scai'let fever very frequently 
occura ; its color varies somewhat ; it is not contagious, and it wants the 
general symptoms, the throat complication, hot skin, quick pulse, and 
tongue of scarlet fever. It is due, no doubt, to some volatile poison free 
in the blood. It has no gravity. 

Little is known as to the cause of roseola. The varieties above-named 
have little light to the distinctive appellations. The causes, according to 
some, are legion — heat, cold, ingesta, initation of delicate skin, gout, 
change of season, acidity, «fec. 

77<e Proynosis Oifei*s no point of gravity or interest. 

The Diagnosis. — Roseola is likely to be confounded with rubeola, 
scarlatina, urticaria, erythema. In reference to it as contrasted with rubeola 
and eiythema, Devergie makes some excellent i*emarks. He says the 
roseolous eruption always occupies a surface of the body more or less ex- 
tensive, commencing frequently about the breast or abdomen, or upper 
limbs ; and generally the surface is studded with many little confluent rose 
sjwts, between which the healthy skin is visible : the spots are largest about 
the breast, smallest on the limbs; oftentimes, the surface is dotted over 
with rose spots. From it/.beola especially it is known by the absence of 
catarrhal symptoms, coiyza, «fec. ; the want of relation between the febrile 
symptoiDS and the amount of erui)tion ; the absence of epidemic influence ; 
the irregular character of the eruption : it is not crescentic, not uniform, 
not dark ; but irregidar, rosy, and often commencing about the breast or 
arms instead of the face : by the circular sha2)e, irregular course, and 
frequent limitation to one locality. 

In erythema, the 8haj>e8 of the patches, giving rise to E. papulatum, E. 
marginatum, and E. nodosum, are peculiar ; the color is not rosy ; the 
blush at the edge becomes puq)lish ; the red blushes are less numerous, 
more diffuse ; the general symptoms are rheumatic, and less acute. 



ROSALIA. 53 

In scarlatina^ the asj>ect of the disease is gi-aver ; the fever is marked, 
the throat is bad, the tongue is peculiar ; the skin harsh, dry ; the i-ash 
general, punctiform, boiled-lobster like. Tlie progress is more uniforai, and 
it can be traced to contagious or epidemic influence. 

In tirticariay the diagnosis is at once settled by the discovery or produc- 
tion of a wheal, and the peculiar stinging character of the local irritation, 
with the capricious character of the eruption. 

The Treatment consists in that which is merely tentative : so far as . 
general measures are concerned, in giving salines, aperients, laxatives, <tc., 
and treating any special symptoms. Locally, in removing all causes of 
irritation — c. e/., instated and tender gums, by lancing ; acidity of stomach, 
by magnesia, soda, or lime-water; intestinal irritation, by "alteratives," 
such as gray powder, rhubarb, and subsequ^^nt tonics, keeping up the 
warmth of the surface, and, if possible, bringing on perspiration. The 
surlEace should not be chilled. My general plan is to give salines vdih 
ammonia, a mild aperient, and then quinine. 

ROSALIA. 

Now, under this term has of late years been described a form of epidemic 
roseola, which sometimes assumes the aspect of "measles, but mostly of scar- 
latina. Under the head of loibella, ** anomalous exanthem," erythema scar- 
latiniforme, I have referred to this disease ; and I think it as well to give 
here a genei'al resum^ of the matter. Well then, in certain cases, after 
slight febrile symptoms, a rash develops pretty generally over -the body ; it 
sometimes looks like measles, but is too fully develo2)ed ])erhaps in the limbs, 
too little in the face, and there are no catan'hal symptoms present ; at 
other times it is exactly like scarlet fever, save in regard to general pyrexia 
and throat symptoms. It does not give rise to desquamation or kidney 
disease. According to the aspect, therefore, of the rash and its color, has 
the disease received appellations that ally it to measles on the one hand and 
scarlet fever on the other ; hence the terms rubella, rubeola notha, rosalia, 
anomalous exanthem, erythema scarlatiniforme. Its cause we do not know. 
The treatment is rest in bed for a day or so, warmth and light food. Tlie 
most impoi-tant point is to be aware of its existence, that we may not con- 
found it with true measles and scarlatina. 

III. URTICARIA, OR NETTLE-RASH. 

This is a febrile and non-contagious disease, in which are produced here 
and there on the skin i*eddened elevations similar to those that follow the 
sting of a nettle (urtica). Tlie symptoms are general and local, therefore. 
When the disease is well marked there is more or less fever, quick pulse, 
dry skin, headache, malaise, mostly pain at the pit of the stomach, and often 
irritation of the mucous membrane of the intestinal tract, whilst on the 
skin ap{)ear what are termed wheals or pomphi : these are accompanied by 
tingling and burning ; they suddenly come, and almost as suddenly go, with- 



54 URTICARIA. 

out leaving any stain behind or desquamation. The eruption may attack a 
small part of the body, or the wheals may sprirg up quickly in succession 
over a much larger area. Wheals may be thus described: at first a bright 
flush ai>i)ears, the centre of this becomes slightly elevated, and pales, hence 
api)eai*8 of lighter color ; the tint may be rosy, but more generally it is 
whitish. These wheals vary in size and shape ; they may be linear, bandlike, 
irregular in outline, or oval ; the white centre, which feels hard and raised, 
may be small, and the red halo large, or a large red patch may whiten at 
two or three points in its area. In all cases the accompanying sensation is 
a hot, tingling, buniing one. Wheals are evoked readily by scratching. 
Tlie skin generally is remarkably sensitive, and the application of any i^- 
tanit is followed by the production of redness or even wheals ; so that it is 
possible by using the nail of the finger to write one's name or to draw 
figures on the skin, and these are marked out by red lines or wheals produced 
at the seat of the scratchings. Much discussion has arisen as to the nature 
of wheals. Some afiirm that they are produced by spasm of the muscular 
fibres of the skin ; othei-s, by effusion of serosity. It is most likely that 
both these conditions exist in wheals. Certain is it that there is slight 
effusion, and the approximation of two scratches in the aHificial production 
of wheals, and their distancing on the application of chloroform or cold, 
seem to indicate that there is some muscular element in the csxse. It is prob- 
able that the vaso-motor nerves' are irritated, the vascular channels are al- 
tered in consequence, effusion takes place, and, in addition, there is spasm 
of the m\iscular fibres of the derma. The occurrence of effusion is well 
seen when urticaria attacks the face, the breast, or the scrotum, for here 
much subcutaneous oedema is produced. This tlisease attacks all ages ; it hs 
most fre(|uent in spring and early summer, and it may bo intermittent or 
|)eriodic. 

Urticaria divides itself into acute and chronic. 

Acute includes — Chronic includes — 

U. febrilis. U. evanida. 

U. ab ingestis. U. perstans. 

U. conferta. U. subcutanea. 

U. tuberosa. 
In the naite varieties there is moi-o or less fever, well-marked symptoms 
of stomach derangement, such as nausea, white and dry tongue, thii-st, quick 
pulse, headache, and general malaise. I have noticed in most cases the 
hue of the face to be bright, as though there was a faint rosy suffusion. 
Tlie itchiness and stinging accompanying the eruption of wheals (w^hich are 
scattered) are well marked, especially at night, and altogether the disease 
puts on an active aspect. The skin is initable, and wheals arise easily 
from irritation. Tliis, the typical form of the disease, is called U. fehrilis. 
When the wheals are more closely packed together — coalescing (conferted) 
— the variety U, conferUi, is present. These two varieties, which are really 
diffei*ent phases of the same tiling, last seven, eight, or ten days or more. 



PATHOLOGY. 55 

and in the conferted there is perhaps more swelling of the skin than in the 
simple variety. Urticaria ah ingestiay as the name implies, follows the 
taking of special articles of food, and it may assume a veiy acute and severe 
form. It is sudden in its appearance, but quickly subsides. In the worst 
forms the patient seems poisoned, there is high fever, vomiting, headache, 
quick' pulse, delirium, the mucous surfaces being hot, initable, tingling, 
the conjunctivw implicated ; presently the face rapidly swells, so that the 
countenance is completely masked ; the ears, nose, eyes, and lips are swollen, 
hot, tingling; the mucous membrane of the larynx is evidently afflicted ; 
the sw^elling speedily subsides and travels to the body and trunk, and this 
very rapidly. It is accompanied by intolerable itching, and the formation 
of wheals is attended with alleviation of the general symptoms. Desqua- 
mation to a slight extent succeeds. The substances that generally act as 
excitants are shell-fish (especially mussels), pork, prawns, lobsters, oystei-s; 
but eggs, fruit, rice, raspbenies, strawbenies, mushrooms, cucumbers, coffee, 
etc., and the generally harmless articles of diet, in cdi*tain subjects, induce 
it ; and so may valerian, copaiba, etc. 

Tlie chronic fonns may result from the acute, or develop out of a state of 
tolerable health, and without apparent cause. There is little pyrexia pres- 
ent. When the crops of wheals are of pretty long continuance, the disease 
is called per8ta}is. In other cases the wheals are small and very fugitive ; 
but the skin is irritable and the itching intense. This is IT. evanula. The 
name factitious urticaria has been given to that form of the disease which is 
easily produced by mechanical irritation, and is not idiopathic. 

In })er8on8 broken in health, especially by intemperance, the urticated 
patches are raised, in consequence of the implication of the subcutaneous 
cellular tissue, in patches about the size of a nut or walnut ; they show 
themselves on the limbs, and i)08se8K the especial feature of urticaria — viz., 
quick appearance and disappearance, or intermittence ; it is called U. 
tuberosa. In some cases there is swelling and apparent cedema of the 
cellular tissue — now here, now there ; but the wheals are more or 
less scarce and occasional. The redness, the heat, the tingling, and 
swelling exist, but it is only the accidental appeai*ance of the wheal that dis- 
closes the true nature of this variety, called IT. aubcutanea (Willan) or 
cedematoaa (Haixly). Even here capriciousness is marked ; the cedema goes 

quickly. 

In some cases, in elderly people, who are apparently in good health, urti- 
caria may assume the charactei*s of evanida, perstans, and tuberosa together. 
I have seen several of these cases ; the only likely cause appeared to be dis- 
ordered digestion, with flatulence, pain after food, etc. In these cjises the 
tongue was suddenly swollen so as to almost fill the mouth, the eye was 
closed, the face puffed out on one side, the scrotum and penis become enor- 
mously ojdematous, and tuberose patches of urticaria showed themselves 
about the arms or the legs. Such a case was lately under my care. It 
seemed to me that bottled beer was the exciting cause. I could not 



56 PATHOLOGY. 

prevail upon my patient to forego it. These chronic forms in some cases 
are truly periodic. 

Pathology, — The following case, related by Dr. Heusinger, of Marburg, 
may well illustrate the pathology of urticaria. In a boy aged sixteen, 
** when lines were traced on the skin, the course of the lines, in the space of 
half a minute, reddened ; and upon this reddened base there quickly rose 
up white ridges or wheals, so that in two or three minutes the lines of the 
writing stood up in strong relief, as exact in figure as if they were cut in 
marble by the most able sculptor. At the end of thirty or forty minutes 
the writing subsided and vanished completely, without leaving behind a 
trace of its presence. When the red lines appeared they were accompanied 
with an elevation of temperature sensible to the young man himself, and 
amounting to \\ or 2^ degrees of Centigi-ade, and when pricked with a fine 
needle, the wheals gave forth a minute drop of serum, as do the wheals of 
urticaria ; but however much or frequently the experiment was repeated, 
the body felt no inconvenience. In explanation of the phenomenon, it is 
ob\'ious that the stimulus applied to the nerves of sensation was reflected 
upon the skin in the form of redness, heut, and swelling." * 

In urticaria it is supposed that the wheals are due to the presence of fluid 
in a circumscribed space, this oedema being due to the escape of fluid from 
a " cluster of capillary loops springing from a common stem, and under the 
influence of a common nervous twig." 

Now, what is the sequence and nature here of the phenomena ? A mor- 
bidly sensitive skin ; initation apjilied : spasmus of the muscular fibres of 
the skin, and also of the capillaries, with subsequent dilatation. Hence 
hyi)eriemi:i, or redness, escape of serosity elevating the central part more 
than the outside of the lines, the whole constituting what is termed a 
"wheal." Ths tUfsues are ^)a*«it;e, it is an altered state of circulation fol- 
lowing nerve disorders ; the altered condition of the nerves of the skin is 
the basLs of urticaria, and the disordered sensation, burning, tingling, etc., 
preceding eruption, indicate as much. Granted this, it is easy to see that 
wheals may bo evoked in many ways: (1) by local irritants, (2) by the cir- 
culation of acrid or elfete products in the blood, which, coming to the sur- 
face, become oxidized and more active, and (3) by reflex irritation. Under 
the first head, or local excitants, rank the acarus, fleas, bugs, mos^piitoes, 
lice, flannel, the contact of numerous other irritants, such as **jelly-fi8h." 
Under the second head must be placed those changes in the blood induced 
by gout, rheumatism, or disordered digestion, the circulation of medicinal 
substances, such as valerian, copaiba; and under the third, pulmonary, 
gastric, uterine, renal disorders, mental anxiety, and emotions of vanous 
kinds. In all these cases there is an influence that directly plays ui)on the 
disordered susceptibility of the cutaneous nervous plexus. Urticaria mostly 



♦ The case is recorded in Virchow's " Archiv Itir Pathologische Anatomic und 
Physiologic uud flir Klinische Medicin,*' June, 1807. 



PROGNOSIS. 57 

arises, however, from stomach disorder, and the nature of tlie latter Ls such 
as to lead me to imagine that the solar plexus is oftentimes involved, the 
mucous surface being morbidly sensible to even ordinaiy iiigesta, fish, beer, 
etc. In very many cases the urticaria is not due so much to the circulation 
of any irritating substance or product, as to the reflection of impressions 
made on the stomach. We have ample proof that tliis is possible and likely, 
in the occurrence of flushing of the face after meals, and chronic erythema, 
consequent upon dysi>epsial symptoms. It is important to add that in some 
instances we are enabled to discover distinct stomach or hepatic derangement. 
Tlie type of the stomach derangem(»nt is j)yrosis. In many cases the seat of 
the I'eflected disorder is not the stomach, but the lowest i)art of the oesophagus. 
In chronic cases I am not sure that irritation at the neck of the bladder is 
not sometimes an excitant of urticaria, and in females U. tuberosa follows 
uterine disturbance, according to Fouquet. If this general view of urticaria 
be taken it will be likely to lead to the adoption of a successful treatment. 

It may be worth while to mention that in the Brazils, the fruit of the 
Paullinia sorbilis (Sapindacese), an ally of coffee, when mixed and taken as 
it constantly is with water, as a drink, j)roduces urticaria. The drink is 
called guanara. Asthma has on many occasions been seen in association 
with ui-ticaria. Dumontpallier has re])orted a case of intermittent urticaria, 
in which the attacks appeared each night for six weeks. The parents were 
both asthmatic, the gi*andfather asthmatic, the grandmother had angina 
pectoris and rheumatism, the brothers were rheumatic, and four of the 
children suffered from intermittent diarrhoea, alternating more or less with 
actual urticaria. 

Prognosis, — Urticaria has no gi*avity about it. Acute attacks (ab in- 
ffestis) are of sliort duration. Chronic urticaiia is abominably troublesome. 
The intermittent form is very obstinate. All depends upon our ascertaining 
the cause of initation (direct or indirect) present. 

Diugnosis, — Urticaria ought not to be mistaken for any other disease. 
Its sudden and capricious character, the tingling sensation, the presence of 
wheals, gastric disturbance, and irritability of skin, are absolutely diag- 
nostic. I have seen it mistaken for scarlatinal rash ; but the error was soon 
detected by irritating the skin and the appearance of wheals. The eviuies- 
cent character of the wheals distinguishes urticaria from the erythemata ; 
and in the instance of lichen urticatus, there are pruriginous papules and 
few wheals, the eruption is of smaller size, feels hard and more persistent ; 
the disease is really a compound of lichen and urticaiia. It is the peculiarly 
capricious character which distinguishes urticaria. U. tuberosa wants the 
regular and persistent course, the lividity, the soft feel, the oval shape of 
erythema nodosum. 

Treatment. — ^Thoroughly unsatisfactoiy is the treatment of urticaria laid 
down in books. *' Correct any digestive disorder, improve the general 
health, and use remedies to allay itching, is its sum and substance," We 
have to deal with a sensitive skin ; first of all it is our duty to prevent that 



58 PELLAGRA. 

being in any way dii'ectly irritated ; flannels should be removed, the utmost 
cleanliness should be observed, no sudden change of temperature should be 
permitted to play upon it, either by way of exercise, draughts, or the like. 
Then we seek to soothe it, by emollient and alkaline bat^s, anointing it if 
possible with oil. We should seek to relieve the skin, to give it rest by 
throwing more work on the kidneys, and by the exhibition of saline apeii- 
ents. Then we must prevent the circulation of effete products, urea, uric 
acid, and control all kinds of disorder wliich may be reflected on to the skin, 
and lastly, tone up and lull by anodynes the nerve paresis. These are the 
principles of treatment. I find urticaria one of the most difficult and unsatis- 
factory of all diseases to cure. The acute are more satisfactory to treat than 
the chronic cases. 

The following is a resutn^ of what appears best to be done : — 

TJ. febrilis. — In simple cases, saline aperients, milk diet, no stimulants, 
alkalies largely diluted, alkaline baths, half a pound of cai*bonate of soda in 
an ordinary hip bath twice a day, lotions of bichloride of mercury, and rose- 
water, or cyanide of potassium. Amongst the Formulae other local reme* 
dies will be found. 

If the patient be gouty, colchicum should be given with salines ; when 
fever runs high, I have usually given acetate of potash, tincture of digitaliA| 
with even potassio-tartrate of antimony. I should expect much from the 
tincture of vei-atrum viride. 

U. ab ingestis. — An emetic (zinc or ipecacuanha), a saline purge, and 
subsequently a mixture of carbonate of ammonia, prussic acid, and infusion 
of cascarilla. The treatment of chronic urticaria is most tiresome and diffi- 
cult. One has to analyze carefully every function of the patient, and it 
requires no little patience to arrive at a distinct conviction that what we 
are doing is a reasonable plan of treatment. If there be mental disturb- 
ance, change of scene does good. Pyrosis, atonic Myspesia, deficiency of 
bile, inaction of the liver, non-excretion of urea, uterine disorder, must be 
treated upon general principles. Generally speaking, it is possible to dis- 
cover some one thing which taken internally evokes the urtication : it may 
be beer : it often is, or condiments of some kind. Where it appears that 
the functions of the body generally are properly performed, bromide of am- 
monium, or if the disease be periodic, quinine is useful ; aconite is 'another 
remedy ; arsenic is much vaunted ; I do not know that it has done much 
good in my hands. 

PELLAGRA, OR ITALIAN LEPROSY. 

Tliis disease is common in Lombardy, about Venetia, Piedmont, South 
of Fi-ance, in some pai*ts of Spain, and Corfu. It attacks the poorer popu- 
lation to the extent of four or five jHjr cent, in the districts where it is 
most i)revalent. Pellagi^a is a general disorder of the system ; the exteraal 
manifestations are only a part of graver changes in the system at large. 
The symptoms arrange themseves into three groups : — 1. Signs of dimin- 



ETIOLOGY OF PELLAGRA. 69 

ished general power, and failure of nutrition ; 2. Cerebro-spinal symptoms ; 
and 3. An einiption of an eiytliematous type. 

After exi>osure to the sun, the pellagrous subject feels in some part of 
his skin, upon which the sun has played, a tingling sensation ; at the same 
time he becomes weak, feverish, the appetite is faulty, digestion is inactive, 
and diarrhoea troublesome. The cerebro-spinal symptoms, the result of in- 
anition and the morbid blood-state, are headache, giddiness, impairment of 
special senses, cramps, convulsive movements, loss of muscular power. The 
patient dreams, and is despondent. 

The eruption makes its appearance on the exposed parts — e, g,y the back 
of the hands, the outer part of the forearm, the forehead and sides of the 
face, the upper part of the chest and the JGeet, more or less, in the spring, 
and is supposed to be excited by the sun^s rays. In the men who wear 
large straw hats the face is not so greatly affected, but the uncovered faces 
of the women suffer more. Red spots first appear, which quickly become 
dark and desquamate ; the surface beneath the scaly covering is red, thick- 
ened, rough, and fissured ; there may be pain ; and little bullae, it is said, 
may form, which die away and are replaced by bluish stains. In some 
cases the epidermis is shrivelled, thin as if frozen or scaly. The eruption 
subsides in the winter. In the ensuing spring the whole thing is exagger- 
ated, increasing from year to year ; each year the intermittence is marked 
by the increasing permanence of the discoloration. In the later stages 
these different symptoms intensify pan pass^i. The patient emaciates : 
phthisis or anasarca sets in ; tlie skin is dirty, unhealthy, '^ callous ; " de- 
lirium, mania (suicidal, it is said), melancholy, epilepsy, idiocy, and hebe- 
tude, have each their victims. A typhoid condition is the necessary result, 
and death ends tlie scene. It has an average duration in fatal cases of five 
years. Sporadic cases may occur in England ; they take the form of an 
erytliema about the back of the hands, with cerebro-spinal symptoms and 
debility. 

JEiiology of Hie Disease, — Now, much has been done of late to place us 
in a position for forming a good estimate of the character of the disease. 
It« frequency is known : in 1830 statistical observation showed that 20,000 
out of a million and a half of the Italian population were affected ; this is 
somewhat about one-sixtieth of the people. Ballardini states this. It ap- 
pears that in about 90 per cent, the pellagrous are poor peasants, about 7 
are artisans, and 3 follow other occupations. 

Opinion differs as to the influence of hereditary tendency, because the 
members of a family are generally placed under exactly similar cii cum- 
stances, — those very ones which probably engender the disease. Caldeiini 
noticed in 184 families (comprising 1,3 J 9 membei-s), inheriting predispo- 
sition, that 648 were diseased, C71 healtJiy. Pellagi*a is said to be the 
result of insanity ; this has been especially insisted upon by Billed. It ap- 
pears that in Billod's asylum (St. Gemmes), patients are affected by pella- 
gra, whilst the inhabitants of the village near (1,700 souls), and those of the 



60 ETIOLOGY OF PELLAGRA. 

entire distiict (22,000), are fi*ee from it. But it has to be shown that the 
inmates are not under the influence of exceptional conditions. It is a fact 
that the insane are affected. Dr. Landouzy determined this question by a 
special journey through Spain. He visited 44 asylums, in which were 
22,873 lunatics, but of these only 73 were pellagrous. Pellagra, says Dr. 
Landouzy, in asylums is only a matter " of general hygiene and alimentii- 
tion." During the five years ending 1861, only 310 cases of pellagrous 
patients have been admitted into the San Servolo at Venice — 82 maniacal, 
2 monomaniacal, 95 melancholic, and 130 demented. Comparing these 
figures with the statistical information already quoted, as to the frequency 
of the disease amongst the general population, it would seem that no ex- 
cessive proportion of pellagrous persons exists amongst the insane, they are 
attacked in common witli those amongst whom they live, and M. Brierre de 
Boismont has recently given it as his opinion that tlie pellagra is not due 
t6 insanity. The converse proposition is however true. In about 9 per 
cent, the pellagrous have some definite form of lunacy. 

But other causes are assigned for the disease ; the one that finds most 
favor at the present time, is the use of diseased (ergoted) maize, as food by 
the people. Now, it has been objected that pellagra is not known in parts 
where maize is largely used — for example, in Southern Italy, Sardinia, and 
Burgiuidy, the people are not pellagrous, though they use maize largely. 
This may be in pai-t due to the use of a mixed diet, but it is also asserted 
that where pellagi-a is present the niaize used is diseased, and where the 
disease is absent, the maize is sound and unaffected. So that those who 
dry tlieir maize, and keep it dry, escape disease, whilst others even in the 
same district, who do not properly preserve maize, may be affected. This 
seems to have been made out. Generally after wet and unhealthy seasons, 
the gi-ain is Ihible to be attacked by a fungus, the Sporisorium maidis ; the 
maize, if it be not properly dried, undergoes change by the action of the 
parasite. Undoubtedly pellagra is most common after wet and unhealthy 
seasons. But it is still asserted that part of the cause is poverty, misery, 
bad hygiene, malarious atmosphere, bad water, and uncleanly habits ; for 
these must deteriorate the general healtli ; and then there is the exposure 
to the sun and the dry atmosphere of the summer time. Unliealthy sea- 
sons affect man as much as the vegetable world ; and the diseased maize, if 
it bo not the efiicient cause, is a certain index that the atmospheric and 
other external contlitions that play ui)on man are none of the best. 

The French Academy of Medicine awarded a prize in 18(54 to M. Rous- 
sel, and an accessit to !M. Cost^illat, for cei*taiu theses which went to prove 
that pellagra was unknown till the introduction of maize. These observera 
arrived at the conclusion, aftcjr examining apparent exceptions, that diseased 
maize is the real cause of the diseiuse pellagra. A n)ost interesting account 
has been recently given of the dist^ase occurring at ( 'orfu, by Dr. Preten- 
deris Tyi>aldos, the Professor of Medicine at the Univei*sity of Athens, and 
as it coutinns entiixily the prevailing opinion as to the cause of j>elhigra, I 



MOBBID ANATOMY. CI 

cannot avoid summarizing it. Pellagra is said, by t)r. Typaldos, to be of 
recent origin in the island. In 1839 one case was seen by a pi-actitioner ; 
several in 1858; in 1859-60-Gl foi-ty-eight cases were collected. Tlie 
disease exists in 27 out of 117 villages, containing 15,458 inhabitants. The 
disease in one village is in the proportion of 1 to 1,218 ; in another 19 to 
480 of the population. Dr. Tyi)aldos notices that the disease exists amongst 
the very poor, whose staple diet now is bread prepared from Indian com, 
which is called " barbarella." Tlie sui)ply is prepared oftentimes for a week. 
" When fresh cooked it is soft and pleasant to the taste, but when dry, it is 
very heavy and indigestible. Of the persons whom Dr. Typaldos found to 
be laboring under pellagi-a, all without exception had lived upon this diet, 
either almost entirely or in chief pai-t ; and he ascertained that the preva- 
lence of the disease corresponded in the different villages to the extent with 
wliich maize constituted the food of the peasants. Tlius, in some localities 
they entirely live upon or have in addition to maize, bread made with sor- 
gho (holcus sorgum), rye, rice, or wheat, and he found that when such gi*ains 
are used the people wholly escape or suffer only slightly from pellagra. The 
author further contends that it cannot be in consequence of the small i)ro- 
l)ortion of the azotizcd elements in Indian com that the gi*ain is injurious, 
for it has been shown that when lye, lice, or sorgho are used, the population 
do not suffer from pellagra, though those giuius are still more deficicmt in 
azote than maize. Ho finally arrives at the conclusion, that the essential 
cause of the disease is the consumption of maize which has be<jn imperfectly 
njiened or has undergone changes after being gathered, thus adojjting the 
views of Ballardini, as advocated in the thesis of M. Kous.sel, and described 
by Dr. Peacock in a former article of this Review." * Dr. Typaldos ex- 
plains the recent occun-ence of ]:>ellagra in Corfu by the fact that within tlie 
last thirty yeai-s in Coi-fu the vine has been cultivated at the exixjiise of the 
maize, which in consequence is largely import-ed from Albania, I^omagna, 
and Naples. This is, however, as good as that gi-own in Corfu ; but grain 
is also obtained from the Danubian provinces, and as it has to midergo a 
long sea voyage it is considerably damaged and often mildewed. Tliat from 
the Danube constitutes by far the largest part of the grain used in the island. 
Much of the grain sold is diseased, and those are specially pellagrous who 
use it. Dr. Typaldos finally remai'ks, that in 1857, a cold and wet sejison 
prevailed in Corfu, the gi*ain was imjiei-fectly ripened, and an epidemic of 
|)e]lagra followed amongst those who consumed the unwholesome gi*ain. 

Mwrhid Anatomy, — Our knowledge on this point is deficient. Tlie brain 
is atrophied, the arachnoid opaque, the spinal cord congested, and serosity 
effused around it ; the liver is fatty, the lungs congested, and the tissues 
generally anssmic, and there is thinning of the mucous membrane of the 
intestinal tract. 

As to tlie nature of the disease, if altered maize be the cause, it is " an 



♦ "Brit and For. Med.-Chir. Review." 



G2 MEDICINAL RASHES. 

ergotism." I cannot quite shake off the impression that malaiial in- 
fluences have something to do with the cause, but I admit I have no facts to 
prove it a sound one. 

Prognosis. — The rate of mortality varies much in different districts, as 
greatly as the frequency. Ballardini states that in the Milanese districts 
78 per cent, get well, 13 are uncured, 9 have mental disease, 6 die from na- 
tural causes, and a few ai*e suicides. 

Treatment, — Tliis is plain ; avoidance of ergoted maize, change and variety 
of diet, the use of wine, and removal from pellagrous districts ; quinine 
and iron tonics ; avoidance of exposure to the sun, and an impix>ved hy- 
giene generally. 

I append a special note on medicinal rashes, as they are mostly erythe- 
matous. 

MEDICINAL RASHES 

are important to remember. Hardy has especially noticed an eruption pro- 
duced by the inunction of mercurial ointment. It is an erythema upon 
which vesicles form, and pour out a thinnish, clear fluid. The vesicles are 
quickly broken, the contents desiccate, and the redness remains for a week 
or ten days. It is clearly a local disease^ and not a true eczema. 

The nitrate of silver discoloration needs no further comment than this, 
that the silver seems to be deposited elsewhere than on the skin — the lining 
membrane of some vessels, it is thought. « 

Arsenic is said to give rise to eczema. I have never seen this : but cer- 
tainly a lichen well developed about the face, neck, arms, and hands, and 
erythema of the palms of the hands, with violent fever, are sometimes pro- 
duced. I am positive it can give rise to double vision by disturbing in 
some way the accommodation of the two eyes. It can also induce erythe- 
ma, especially of the face, and a puffiness about the eyes, — I mean in small 
doses, and during its. early exhibition ; and it has hapi>ened to me to see the 
best results under such circumstances from perseverance ip its use, notwith- 
standing these occurrences, provided there are no gastric symptoms. I 
have seen herpes zoster come on during its exhibition, and some think that 
it may give rise to this disease, but I am not disposed to believe by any 
dii'ect influence, but that out of the changes that its use induces a condi- 
tion may bo brought about favorable to the occurrence of zoster. 

Iodine sometimes produces erythema of the face, and local inflammation 
of course. 

The friction of croton oil into the skin not unusually gives rise to an 
erythema of the face. I have been in the habit of using this topically and 
extensively for certain forms of dyspepsia, and I have often seen this ery- 
thema of the face occur in a symmetrical manner, lasting for a few days, 
with distinct heat, and this where there could have been no direct a})plica- 
tion of the remedy to the face. 

JBromiile of potassium may give rise to erythema and swelling of the 



MEDICINAL RASHES. 63 

nose ; at least in one case this appeai*ed to be its constant action. In the 
experience of those who have given the dnig largely, an ecthyinatous eruption 
may follow its use ; but this is probably due to its '' loweiing " or " liquefy- 
ing " action, as in the case of iodide of* ^>oto*#iM//i, which may induce pur- 
pura in a predisposed subject, and of coui-se the erythema and other symp- 
toms of iodism. 

JSeUadonna produces a rash of rosy hue, fever, and a dry throat, with, of 
course, dilated jmpils, whatever may be said to the contrary. Dr. Fuller 
has denied this, but I caimot but think, esi)ecially having regard to the large 
doses he has given without effect, that his extract has been inert. I am 
confirmed in my opinion by several communications from eminent physi- 
cians. 

Copaiba iilduces a rash well described by Judd in his work ; a rosy er}'- 
thema, of " pumiceous " aspect, as though the skin had been bitten by in- 
sects. 

Arnica may produce erythema and swelling of the part to which it is 
applied, and excite acute eczema. 

JSuIphur, in some cases, gives rise to a dr}', red, dirty aspect of skin, with 
an attempt at the formation of vesicles, perhaps an ai-titicial eczema, and 
Bubseqnent pityiiasis, accompanied by much itching ; mistaken for the con- 
tinuance or increase of the oiiginal diseases, mostly scabies, and demanding 
the most soothing treatment. A recent case I saw was that of a gentleman 
who had scabies ; he had been ordered a series of sulphur baths, which set 
up an artificial eczema, with ecthyma from the scratching, that rajiidly got 
well (sooner than usual in these cases, for the sulphur impregnates the sys- 
tem) by demulcent baths and soothing unguents. Sulphur baths should be 
used with gentleness, and I think the old-fashioned villanous compound sul- 
phur ointment less vigorously than is customary, for I feel sure that it is 
often continued long after the original scabies is cured, and upon which the 
secondary effects, erroneously regarded as the thing to treat, de]>end. I 
have seen grievous errors committed from a want of attention to the facts 1 
have pointed out. 

I had almost forgotten to mention that i)hosphonis produces chronic 
ulceration, guanara (coffee tribe), urticaria. 

Formula* for erythematous diseases, Nos. 42, 44, 49, 52, 53, 59, GO, 69, 
90, 94, 105, 123, 129, 132, 138. 



CHAPTER VIII. 

CATARRHAL INFLAMMATION, OR ECZEMA. 

I CONSIDER it ver}' necessaiy to give a pretty full account of eczema, be- 
cause I venture to hold opinions which concide with those of Willan, and 
are therefore opposed pathologically to the views of almost everv modem 
authority and writer upon tJie subject. I am compelled to tliis from a con- 
viction, long founded, frequently re examined and tested, but which seems 
to me more than ever to be in accord with clinical facts. I will firat state 
what eczema appears to me to be, and then append and examine tlie views 
of Hebra and others. Typical eczema is an acute inflammatory disease, 
cbai*acteiized especially by an eruption, in connection with more or less 
Buperlicial redness, of small closely-packed .vesicles, which quickly run to- 
gether, burst, and are i-eplaced by a slightly excoriate|l surface that pours 
out a serous fluid, which dries into crusts of a bright color, and of moderate 
thickness. The crusts ai-e composed of blastema, pus-corpuscles, epithelial 
cells in an ill-developed state, and granular matter of an inflammatoty and 
fatty nature. The discharge has the very peculiar property of stiflfening 
linen. The vesicles appear in successive crops, and may prolong the disease 
for an indefinite^ time. They are attended with itching and local heat. The 
skin is initable, occasionally excoriations or crackings of the part occur, 
the time skin itself is somewhat infilti-ated, and sometimes the parts around 
the imtch inflame, probably from the instating nature of the discharge. 
The patches foi-m on various parts of the body, are of vaiiable size, and 
mostly symmetrical. If the disease is extensive and general there may be 
Bhaq> pyrexia. Generally speaking there is a pallid lymphatic aspect, head- 
ache, loss of appetite, thirst, dirty tongue, confined bowels, and the like. 
T!ie mucous surfaces may become the seat of inflammation, either by the 
spread of disease from the skin or as a consequence api)ai*ently of the general 
condition. The disease is the most common of all skin diseases ; it lasts a 
varying time, in conse<pience of successive local developments, and the ten- 
dency it has to spread. In the chronic state it often oscillates between cure 
and i-ecurrence ; the skin gets harsh, dry, red, and thickened. After its 
disappeaiiince it leaves behind no traces of its fonner presence. Its retro- 
cession is said to be followed by grave symptoms. 

Now, this typical form of eczema is not often seen, but it does exist ; and 
one of the most marked cases of the kind came under my care at Charing 
Cross Hospital not long since. Tlie varieties are thi*ee — eczema simplex, 
eczema rubrum, and eczema impetiginodes. The varieties differ in i-egard 
to the extent of inflammation (amount of structure involved), and the 



ECZEMA. 65 

degree of puriformity of seci-etion, this being dependent upon the constitu- 
tion of the patient. 

E, simplex (called by Willan E. solare, when slight, because it is often 
brought into existence as a consequence of the action of the sun's rays) is 
the typical form. It may be local or more or less general. It is also ex- 
cited by irritants of all kinds — heat, cold, soap. If it be in the hot season, 
the patient complains of fever, a " heated state of blood," headache, and 
the like ; presently*, on the exposed parts, especially the face, arms, neck, or 
the back of the hands, little clustering vesicles about the size of pins' heads 
appear, in conjunction with slight erythema, heat, and itching. The con- 
tents of the vesicles presently get milky, the vesicles burst, and slight 
yellowish crusts are formed. The duration of the disease varies very 
considerably. It is often short, often long, according to the extent of 
the succession of vesicles. When the disease is extensive, pyrexia is 
marked. 

JEJ. rahnim is the inflammatory form ; the general symptoms are often 
severe, the headache, fever, thirst, and foulness of tongue are decided ; 
locally the part is " hot, tumefied, red, and shining," and upon this vesicles 
(which may require the use of a lens to detect satisfactorily) form, and 
Roon become confluent. They speedily burst, give exit to their contents, 
which desiccate, and give rise to yellow or brownish scabs ; the secretion is 
ichorous in character, and causes considerable invitation to anv surface 
around with which it comes in contact. The whole patch becomes excori- 
ated, the burning pain is often very severe, and the disease spreads. It is 
generally observed about the flexures of the body, in the thigh, the groin, 
the elbow, the axilla?, and about the wrists ; sometimes it is i)artial, or it 
may run more or less over the general area of the body. E. rubrum varies 
in degree ; when it is very severe, the amo\int of discharge is large, the 
crusts are thicker, the surface is more inflamed, and excoriated to a high 
degree. The transition from the simple to the inflamed eczema is easy. 
E. mbrum is apt to become chronic in old people ; when it occurs about 
the legs, is often the starting-point of ulcers. 

Eczema Impetlf/inocles, — This is eczema occurring in a lymphatic or de- 
bilitated subject, especially young children, and since there is more or less 
of a pyogenic habit present, the corpuscular element in the secretion is in 
excess. It is therefore often styled a pustulo-vesicular disease. Tlie gen- 
eral symptoms are much the same as those of eczema rubrum. There are, 
locally, a good deal of inflammatory heat and rc^dness ; the vesicles which 
appear contain a serosity, which is speedily mixed with pundent secretion. 
The discharge and subsequent drying of this tenacious fluid fomis iiTegular 
greenish-yellow thick scabs and crusts, beneath which is a red and hot sur- 
face : this form of eczema is veiy common (35 per cent.), and is not as a 
rule general but local, confined oftentimes to a limited surface. In infants 
the sebaceous glands often become instable, and pour out a large quantity 
of fatty matter, whereby the disease is increased in severity. This variety 



e6]iecially occurs in the head, niid in iiifaiits. The deBciiptioi] 
infantile to be given directly will aj'ply to its ecverer forms. 

If I were obliged to give u short deBci-i]>tion of eczema, I Ebould aay 
it is a " catarrhal " ixiflwimiation of the skin, modified by the constitultoa 
of the patient. Now, any of these three varieties may become chronic, am] 
in that case the amount of discharge may be free and irritating; this has 
been called E, iciwrogutn .• or it may lesijeu, but sufficient i-emains to give 
lise to continuous ci-usting, or wha-t ia ajiparently only scalineBs. Hence 
the disease has been termed ecxema sqvainimtm. If cracks occur we have ■ 
raw, red, perhaps an exuding, crocked surface, termed E. JUtum (£, 
feudille of t}io Fivncb). It ofleutimea results from the movemcntH of the 
mouth : again, induration may he a conseqiience, or the skin about the 
patch may become lEdematous or warty, or specially thinned, or the fibrous 
structures may greatly hypertrophy, and a huge shapeless moss, with &ce 
ulceration, result. Hence other vaiieties ha%'e been made, such as E. 
ttdemaUmtm, verruecmim, lelerofum, tparffoaij'omte, and so on. But reftlly 
to dignify all these secondary chanties by an elevation to the position and 
rightA of special varieties is to me highly objectionable. Tiie induration, 
papillary growth, and the like, have their origin really in certain specisj^ 
deviationa of the tissue nutrition itdelf, the ecxemu being the exciting 
cause, and we liave to treat not ecKcnia iu these cades, but other con- 
ditions of hvjjertrophy or ati-ophy which we see occurring when eczema 
is absent ax well as present. Eceema squamosum and pityriaids are 
often regarded as the same. In the former the scaliness is secondary; 
in the latter (pityriasis), a jirimary form of disease — two toUdly diiTer- 
ent conditions. Ulceration occurs aft^r eczema : should that be made a 
variety ? 

We find, then, clinically, that in some cases the " discharge " feature of 
eczema is not no well marked as in others. It may be abortive, and then 
the erythematous aapect may predominate, the exudation may be slight, and 
only ndse the cuticle into what appears to be papulation; or pus may be 
readily praduced, or the secretion may quickly be re-absorbed, and scales be 
produced or fiseuring result at an eiuly stage. It has been thei'efore wud 
that eczema may commence as an erythema, a jiapulation, n veaiculation, a 
pustulation, a sipiamation, or a fisstu'e. I deny it. Any of these stagee of 
inflammation and its iintults may be quickly arrived at or specially 
presoi-ved, but in all cases the tendency is to the outjiouring of a Iwgfi 
quantity of serosity of sjiecial (juality from the skin. This necessarily 
tends in the first place to the uplifting of the cuticle by the tiei-oaity — 
i. «., tbo production of vesicutation, which is rapidly over, because the 
cuticle bursts, and dischai^s the fluid ; but the t<*ndency to fi'ee secre- 
tion exists, and is the main feature in the diaease. (This is "catarrhal" 
inflanunation.) And this vesicular stage is generally passed when the 
disease comes under the notice of tlie physician, tliough v<!siculatioa 
tnay, with care, be made out at tbe edge of a patch which is on the in- 



ECZEMA. 67 

crease. It is manifestly unfair to estimate its value or probable occurrence 
in a disease which is stationary or in progress towards recoveiy* 

But there are certain other varieties mentioned in books which must 
be briefiy described. In the first place E. infantile. This has the 
characters of eczema rubrum and eczema impetiginodes more or less combined. 
There can be no doubt that it is a very obstinate and severe disease. 
We often see this form of eczema run through almost all the stages 
represented by the disease collectively. It generally commences as an 
acute attack, subsides into a chronic state, which may last for a very 
long time, even years. The child is thin, pale, pasty, takes food badly, 
&c. When the eruption first appears, its aspect is really a compromise 
between E. simplex and E. rubi'um ; the discharge then alters its character, 
and E. imj>etiginodes is presented to us. The local signs of irritation 
are more or less marked ; there are heat, itching, pain, swelling, excoria- 
tion, rawness, or ulceration ; the secretion may be thin or purulent, the 
glands near are swollen, and according to the aspect of the part attacked, 
whether moist or dry, the disease has received various names — e, [/., tinea 
grantdata, cruata lactea^ porrigo larvcdis. It affects all pai*ts, but especially 
the scalp, buttocks, axillse, ears, and flexures of the joints. The child 
gets feverish, loses flesh, and marasmus may come on. If not properly 
treated, the disease becomes very chronic, and the child a pitiable object. 

There are several chief situations in which eczema is found, and au- 
thorities have hence described several local varieties. There is no part 
of the surface exempt from the disease. 

1. JEczema capitis has been really described a moment since under the 
head of E. infantile. It is seen during dentition, in scrofulous children 
especially; it may extend to the face; pediculi are common among the 
ciTLsta. The glands are inflamed from absorption of the acrid fluid. After 
the acute stage is passed, which is that of E. rubrum chiefly, the secretion 
dries, and the scalp may present one raw, red, cracked surface, covered over 
more or less with lamellar scales of yellowish tint, or crusted all over. If 
there be hair on the head, the discharge mats it into masses, and the hair 
formation is checked — that is to say, the hair is ^^ thinned.'' In the 
process of cure, a state like pityriasis is gone through. The disease is often 
very obstinate. 

2. £J, faciei is often an extension from the scalp, the secretion is free, and 
forms large crusts, generally on the forehead, but also the cheeks and chin, 
the conjunctivae are often red and tender, itching is troublesome. The 
disease is mostly symmetrical, and does not present an uniform aspect ;. here 
it is inflamed a^d red, here it is crusted over, here pustular, and here 
cracked, perhaps. Like the E. capitis, it is often confoimdod with 
seborrhoea. 

3. JS» aurium is another sub- variety. The ear is red, swollen, tender, 
hot^ and tense, the vesicles are often very well developed, and the discharge 
free, drjdng into crusts, which after falling, leave behind a dull red surface. 



68 ECZEMA. 

Xhe disease often extends into the meatus, causing swelling and blocking tip of 
the passage. More frequently, E. aurium takes on the aspect of E. impe- 
tiginodes, then the ear gets hypertrophied, and small abscesses are formed. 
In old people the ear is often affected, in these the disease is very obstinate, 
and the sui-face is dry and fissured. 

4. E. mnmmce is observed during lactation more especially, and is confined 
to the female sex. It is observed around the nipple, and the degree of in- 
flammation varies: sometimes it is slight, at other times the aspect of 
impetigo is assumed, and there is oftentimes a tendency to the formation 
of fissures, with subsequent infiltration, and threateidng abscess formation 
in the lax cellular tissue beneath. The nipple is hot, tender, and often 
bleeds. Hardy says it arises out of three conditions ; in fat people, during 
lactation, and in scabies, and he believes correctly that it is an excellent 
diagnostic sign of scabies. 

5. JEJ. manuum et pedum is chiefly remarkable for the peculiar tenacity 
and persistence of the vesicles, due to the greater thickness in those situa- 
tions of the cuticle. The dispase assumes mostly the aspect of E. rubrum 
on the back of the hands and between the fingers. Tlie fluid in the vesicles, 
seated upon a red base, gets absorbed, and crusts are then formed ; some- 
times bullje arise by the coalescence of vesicles; pruritus is oftentimes 
severe. Presently the patch becomes drier, more scaly, thickened and fis- 
sured, the fissures giving exit to a viscid secretion which concretes into 
scales ; the disease may assume a pustular aspect. The grocers' and bakers' 
itch is according to some authors an eczema of this class. An acute form 
has been descril>ed, wliich commences by marked fever and malaise, the 
tissues generally are inflamed, bullas form, and the fluid being absorbed, 
large scales are detached, exposing a red surface, which gives out a quasi- 
purulent discharge, and this is often followed by a chronic stage. This is 
eczema rubrum. 

G. E. genitale attacks the arms, perineum, scrotum, and vulva, and is 
characteiized by its very free secretion. It often commences at the scrotum, 
which is thickened, puckered, moist and tender, covered with large thin 
scales, the fluid oozing freely from numerous fissures. It often extends 
from the scrotum to the anus, and from the pudendum to the vagina, indu- 
cing a most intolerable itching, with swelling, heat, redness, and discharge. 

Varieties have also been made according to form ; when it occurs in 
round patches the size and shape of pieces of money, it is called E. nummu- 
laris. Tliis is often lepra vulgaiis. 

Eczema rnarghiatum is the name given to a disease which Ls seen at the 
irmer part of the thigh, or the fork : it is generally symmetrical ; there is a 
red, dry, oflen scaly, surface, which sweeps in a circular manner from the 
fork down on the thigh for several inches, and is said to occur in slioemakers 
and dragoons, as the result of heat and moisture. I believe under this term 
different diseases are very likely to be included — intertrigo, lepra vulgaiis, ery- 
thema fi'om pedicular irritation, eczema, and ordinary ringworm of the but- 



ECZEALA^ 69 

face. In regard to eczema and lepra, the diagnosis is determined by the pres- 
ence of eruption elsewhere ; and the parasitic variety of eruption is known 
by its ringed chai*acter, the papule-like edge of the extending disease, the 
clearing centre, and the microscopic detection of the fungus. 

Patltology. — And now I proceed to give the views of Mr. Wilson, and of 
the French and German schools, in regaixl to the nature of eczema. 

Mr. Wilson includes under the term **eczematous diseases" eczema, pso- 
riasis (chronic eczema), pityriasis, lichen, impetigo, gutta rosacea (or acne 
rosacea), and scabies. 

In the French school the existence of a ** dartrous diathesis" is recognized 
and insisted upon, more especially by Hardy. It includes eczema, pity- 
riasis, psoriasis, and lichen, as different expressions of one and the same 
Iiabit of syst^im. Hardy's definition runs somewhat thus : — Dartrous affec- 
tions of the skin are such as possess different elementary lesions, which are 
non-contagious, often transmitted hereditarily, recurring frequently, i)ossess- 
ing a tendency to spread into new localities, accompanied by itching, chronic 
in course, Icjaving behind in process of cure no cicatrices, though accompa- 
nied by slight ulceration, and due to a special blood state, 8\d generis. The 
three chief features are, — hereditary transmission, the tendency to recur, 
and to spread. The general health is apparently good, but not in reality ; 
the surface is dry, the perspiration is effected with difficulty, pruritus is 
common, especially about the anus, the skin is very sensitive, and easily af- 
fected through local irritants. The general predisponents to eruption ai-e — 
the use of alcohol, coffee, seasoned aliments, Jbc. The local eruptions may 
be vesicular, pai)ular, or squamous, and these are often associated. Once de- 
veloped, the eruption has a tendency to affect several parts, and it Ls generally 
symmetrical, subjective sensations are aggravated at night, the mucous sur- 
faces are often affected — ex., the vaginal, the bronchial, intestinal, pharyngeal, 
itc., so that we may have a dartrous leucon'hcea, bronchitis, «kc. The dartrous 
diathesis is seen at all ages, especially in the young, and with an equal fretjuen- 
cy in either sex. Eczema prevails in the lymphatic, lichen the nervous, 
pityriasis the bilious, and psoriasis the sanguimious. Among the exciting 
causes may be mentioned the occupations of baker, grocer, smith, cook, and 
chemical manipulator. The existence of such a constitutionid condition as 
the dartrous diathesis is a question under discussion at the prcs(nit time, 
and admits of much doubt. There are many facts that militate against any 
such hypothesis. Hardy includes impetigo under the head of eczema. 

The French, then, do not go so far as Erasmus Wilson, but include four dis- 
eases (pityriasis, psoriasis, eczema, lichen) under a single class-terai — dartres 
— and make impetigo a stage of eczema. Tlie German dermatologists, 
however, differ altogether from previous authorities ; and we may tiike Hebra 
as the representative of the German school. His fourth class of skin dis- 
ease is entitled exuflntive diseases / two subdivisions are then made into (1) 
disease with an acute — including the acute contagious (scarlet-fever, small 
pox) and the acute non-contagious diseases (erythematous, furuncular, and 



70 ECZEMA. 

phlyctenoid, such as herpes and pemphigus) ; — and (2) diseases with a chro- 
nic course, iiichiding squamous, acneform, pustular, &c, ; and Group 2 of the 
latter class is called piniriginous, and includes eczema, scabies, and prurigo. 
Eczema itself is again subdivided into five sub-classes or varieties : — (1) Ec- 
zema squamosum (pityriasis rubra), (2) E. papulatum (lichen, in fact), (3) 
E. vesiculosum (the E. solare of Willan), (4) E. rubrum seu madidans, (5) 
E. impetigo seu ci-ustosum. Hence Hebra makes pityriasis, lichen, eczema, 
and impetigo stages the one of the other, and related to scabies and prurigo. 
Dr. McCall Anderson and Dr. A. B. Buchanan have founded another classi- 
fication of eczema, as follows: — (1) E. eiythematodes ; (2) E. papulatum 
(including lichen simplex and prurigo) ; (3) E. vesiculosum (the E. simplex 
of authors) ; (4) E. pustulosum, or E. impetiginodes (im})ctigo included); 
(5) E. rimosum (the E. fendillc of the French). 

To take these in order. The " dai-ti-es " I cannot undei'stand. I find Hardy 
saying tliat a disordered shedding of the epithelial scales (true pityriasis), 
an hypertrophy of the papillary and epithelial layers of the skin (psoriasis seu 
lepra vulgaris), a catarrhal inflammation, characterized by the free exuda- 
tion of a {Kjculiar serosity (eczema), and " fibrous " inflammation of the skin 
.(lichen), seated mostly in the papillary layer, belong to one and the same 
class. I find Hebra including a neurotic, t. c, prurigo, a parasitic, i, «., 
scabies (and a vesicle, per se, is no evidence of eczema), and a disease which 
he calls eczema, and which is made to include lichen and pityriasis rubra — 
all dissimilara in toto — under the one term " pruriginous, the designation 
for a sub-gi'oup of chronic exudative diseases." I say it is a negation of the 
commonest principles and data of genei*al pathology to do so. Willan, from 
clinical observation, noticed that there was a disease in which free secre- 
tion of a niarked and peculiar kind took place, in which there was a tend- 
ency to vesiculation, and he marked it out most definitely. That observa- 
tion was true, and vindicates the claim that Willan has to be considered as 
an acute clinical observer, and I attempt to explain by the light of modem 
research the trueness of the position he took in regard to the description of 
the disease wliich he called eczema. I liave thus taken only the clinical 
view of the matter. With regard to the anatomical seat of eczema : this is 
somewhat special. It is the upper portion of the derma and the Malpighi- 
.an layer : and free secretion is probably favored by some attractive influ- 
ence exerted by the cells of this part. The pathological type of eczema is 
that of ^' catarrhal inflammation." It is this which makes eczema as I 
describe it so very distinct. The cell formation in eczema is often active; 
many of the cells are amcebiform. 

Biesiadecki states that the commencement of vesiculation in eczema con- 
sists of the " migration " from the ]>apillary layer towards the surface of 
numerous spindle-8hai>ed cells, which are seen partly in the papillary layer 
:and partly in the mucous layer of the epidermis. But of course all de]>endB 
uiK)n what is meant by eczema. Biesiadecki may take Hebra's view of 
'eczema. This cell change is not common to eczema ; it occurs in condylo- 



ROZEMA.. 



71 



mats lichen, jjemphigHS (as stjited to me by Dr. Sandersoii), and piistiJur dia- 
easea. It is " discharge " ur " fltix " of si>ecial nature that is so chai-acteris- 
tic of ec/ema. It seems to be tlie hori7.ontal plexus of the akin, from whence 
the Bcrosity chiefly comes, hut no doubt the papillary plexus alfio. Now i 
with regard to the cause. It may reiuiily be seen tliiit all infliumces that ] 
t«nd to lower the vital power, such as debility of all kinds — iiutritiTe, 
assimilutivc, nervous — will allow the active ciuise — l.r., cold, heat, inittuits 
of all kjnds, and the like — to have upecial play. I 

It is therefore esByto see how digestive en-ors and derangements, organic I 
diseiifio, deficient elimination— as in gout — wejikly diathesis, violations of 
hygiene (such an deficiency of !ur, cteanliQess, eicercise, olotlijng), change of 
aeaaon, deficient food, overgrowth, nervous shock, deranged uterine function, 
convalescence from acute diseases, vaccination, dentition, and other mal- 
inSnenccs debilitale, and lay the way open to the operation of what are cer- 
tainly the most common exoitant*i of eczema — cold, local irritation, and heat. 
These may impi-eas the nerves of the affecteii part, and ao lend to cell meta- 
moi-phnais, dilatation of the vesBela, and escape of serosity. As r^ards 
frequency, eczema ia aaid to make up about one-third of all the diseases of 
the skin, but it is less than tliia if by eczema we mean " catarrhal " inflam- 
mation. Tile lymphatic temperament is present in the majority of caaes. 

JHitffrwng. — T hold, of course, that the main feature of eczema is the pres- 
ence of a peculiar " discharge," which dries into thin yellow cruets. How- 
ever long-standing any case of eczema maj be, it will always furnish sufficient 1 
evidence in ita history of tlic fact of its being a tiioigt disease. If we attend 
to this jioint we shall very soon discover (what I have rcjieatedly insistml 
npon as an important clinical fact) that in a vast majoi-ity of cases the dis- ] 
ease has exisUMl a long time before it comes under the notice of the prac- 
titioner ; lliat the early stage is nirely seen, only in those cases in which 
the disease is genei'al and severe, and the constitutional affection is sufficient- 
ly gi-ave to compel the patient to seek foi' medical advice at once. The veai- | 
cular flt-ago consequently rarely comes under the eye of the physician. Ask 
the patient closely as to antecedents and lie will often state that the disease 
began with redness, that then little bladders or watery heads formed, and 
tho surface began to " weep " or " discliarge." Where eczema is on the 
increase one mat/ detect the vesiculation at the edge of the [jatch. It is , 
the "catarrhal" aspect of the disease which I regard as so "character- | 
istic." There is as much dilTerence between eczema and lichen as there 
is betwixt bronchitis and jmenmonia; and there is this additional dis- I 
tinctive mark of eczema, that tlie application of irritants will mostly evoke I 
"discharge;" there is a capacity for dischar^ always present that is I 
absent in other sunilar diseases. There are many diseases confounded with 
true eczema ; these vaiy according to the stage and " age " of the eczema. ' 
Acul« (fKTifrtl tcfina may be mist^en in the first place for one of the acute 
■pecific diseases, in consequence of the pyi'exia which is sometimes present, 
y^fta redness, too, has a somewhat punctnted ap|>earauce at ita earliest stage, 



72 ECZEMA. 

but veiy quickly all doubt vanishes by the fact that the eruption is clearly 
out of all proportion, as regards seveiity, ^vith the pyrexia. The patient is 
not so ill as he or she would be if the case were one of zymotic nature, and 
the vesiculation i-apidly shows itself. I have been able to show a case of 
this kind very I'ecently at Charing Cross Hospital. Acute general liclien 
is accompanied by much itching ; it often affects particularly the outside of 
the limbs : though the eruption is well developed and plentiful, it is truly 
papular, the papules feeling hard and dry, and there is no " dischai*ge," and 
no crusting. The inflanunation is decidedly fibrous and distinguished from 
serous, and this applies to all cases of lichen. Again the slighter forms of 
eczema may be mistaken for Erythenie vesiculeux of Hardy, which arises 
from the application of a local irritant, and is characterized by vesicles 
upon a red base ; but the disease is of short duration ; it has no tendency 
to spread, it is localized, the discharge is not viscid, stiffening like that of 
eczema. latertr'ufo is produced by an evident cause — the friction of two 
surfaces ; its seat is in the folds of the skin ; the absence of vesicles, of 
crusts, and the thin muciform secretion, are distinctive. 

No error shoidd arise in diagnosing ordinai-y erythema^ the negative evi- 
dence in regard to discharge and ci-usting sufficing. Erys'qyelas is an acute 
and severe disease, accompanied by shining, tense, smai-ting swelling, upon 
which are developed phlyctenaa ; there are no pustules, vesicles, &c. The 
definite course of the disease — small bullte collected together upon a red 
base, which do not burst, but shrivel away in a few days, and the absence 
of light yellow ci*usts — should define the difference between herpes and eczema. 
In sudamina the vesicles are large, scattered over a large extent of surface, 
developing after sharp pei*spiration, generally in the course of acute pyrexia] 
disease, and drying up in a few days, with slight desquamation. Occasion- 
ally one sees, es|)ecially about the hands (the palms), aformof disease which 
api>ear8 to be an eczema, in which the fluid has collected beneath a tough 
layer of skin, which is somewhat raised if the disease be left alone ; the skin 
peels off in a thickish layer, leaving behind a reddish more or less tender 
surface, which does not cnist over but simply dries. If the disease be atten- 
tively examined at the outset, the fluid will be seen to be perfectly clear (not 
milky), and to be distending, as I believe, the perspimtory ducts, escaping 
thence beneath the upper layer of the cuticle ; it is an idrosis, an acute out- 
pouring of fluid by the sweat glands, accompanied by an inflammatory con- 
dition, and, as a consQ(pience, death of the upper layer of the cutis. The 
disease is always classed with eczema. The treatment, however, is some- 
what different. In scabies the vesicles are scattered, not confluent ; they 
are acuminated, and present the well-known furrow, at whose end the acarus 
lies imbedded and may be detected. Tliere is no inflummatory base as a rule. 
Eczema may be interdigital, and then lead to confusion; but in scabies the 
eruption is seated on the anterior surface of the foreann, about the breast, 
abdomen, the buttocks, and the i)enis ; on the feet, pustules (impetiginous 
and ecthymatous) are present, the itching is intense at night, but relieved by 



ECZEMA. 73 

scratching. In Bcabies crusts contain acari. In the more chronic, the pus- 
tular, and scaly stages, the similarity of eczema to other diseases is a fre- 
quent occurrence. Where the body generally is affected confusion may arise 
in the case of general psoriasis, pityriasis laibra, and pemphigus foliaceus. 
The distinction between general eczema and psoriasis is a matter of daily 
necessity. The history of " discharge " in the eczema case is hero the great 
guide. An eczema so severe as to cover nearly the whole body could not be 
without the " characteristic " discharge at the outset of its course. The 
scales are epithelial in lepra vulgaris, and only partially so in eczema, in 
which the crusts are also made up of blastema, granular cells, pyoid corpus- 
cles (inflammatory products). The disease in lepra vulgai-is, seen generally 
very clearly on the elbows and knees, or head, is an hypertrophy chiefly of 
the epithelial layer of the skin, the capillary portion being involved, whereas 
eczema is an inflammatory and exudative aflair. Nothing is more certain 
than this contrast. The origin of the disease in 2)6mpJdf/us foliaceus \a from 
bnllaa that first show about the chest, and thence invade the general surface : 
they abort, and are replaced by large scales and incrustations, the scales 
being often thick like parchment ; the skin is not infiltrated ; the disease is 
a gi-ave one. Inpityriaais rubra^ as far as I have seen it, there is h dry red 
glazed surface, with slight infiltration of the skin, the formation of scales 
that now take the form of branny flakes, now of large thin squamaa easily 
detached : more extensive plates may form and all be present in one and the 
same subject. In some cases there are patches of skin that i*emind one in 
the feel of a piece of dried bladder, only that they ai*e reddish. There is no 
discharge, merely redness, desquamation, and condensation, without much 
itching, bui*ning, or other uncomfortable symptom. 

When the eczema is not general but local, difficulties frequently arise. I 
include impetigo under the term eczema, save in the case of the contagious 
impetigo, which in its " sparse " and " contagious " nature cannot but be 
recognized. The inflammatory form, eczema rubrum, attacks several regions 
at once ; the rigors, smarting, and pyrexia may make one suspect sometimes 
the advent of erysipelas. When eczema attacks the hands, bullio may form 
in consequence of the coalescence of vesicles, and pemphigus may seem to be 
present, but the presence of the vesicles or crusts elsewhere in eczema, and 
of bullae in pemphigus, will suffice to avoid error. Herpes circincUus (when 
well marked) I have seen more than once mistaken for eczema, but the red 
base with vesicles upon tliis, and the peculiai'ly well-defined and perfectly 
circular shape of the patch in the early stage, and the delicately scaly or 
" frayed " aspect of the herpes, the scales being formerl not so much by dis- 
charge as epithelial scales as seen under the microscope. The detection of a 
fungus should settle the diagnosis. Seborrhcca sicca or squamosa, and even 
seborrhoea oleosa is mistaken, I believe, generally for eczema. There is in 
ordinary seborrhoea no " discharge ; " there is a red surface which becomes 
covered over with little dirty -yellow flat crusts, which are made up of fatty 
and epithelial matters, and on these being picked off, which may be done 



74 ECZEMA. 

pretty readily, the surface beneath is seen to be red, diy, not unusually hot : 
the sebaceous follicles, moreover, being somewhat distended and prominent. 
In other cases the sebaceous flux may be of a more oily nature, and then 
there is less cinisting. There is a discharge, but it is fatty, and there is not 
the cr sting of eczema, and the sebaceous glands often atrophy somewhat. 
But this form of seborrhcea may take on the aspect of eczema faciei, the 
naked-eye difference between the two being the peculiarly oily, honey-like 
character of the discharge in seborrhcea, and the absence of " crusting'' which 
we would expect, having regard to the amount of discharge, were it eczema. 

Lichen circxtniacriptus and lichen agrius may resemble eczema ; the dis- 
tinctly papular and the non-catarrlial nature of the former should suffice for 
the diagnosis. Lichen agrius, or inflamed lichen, has " di^sharge "no doubt, 
but it is not followed by the light-yellow crusts of eczema, the patch is thicker, 
harsher, the scaling more epithelial, the skin generally more infiltrated than 
in eczema. I have no objection to regard lichen agrius as including those 
cases in which lichen and eczema occur together, and which we know as 
lichen eczematodes or eczema lichenodes, particularly as the treatment is the 
same as that of eczema rather than lichen ; but tliis I do say, that you may 
have an 'inflamed lichen, simulating but distinct fix>m true eczema, in the 
same way that you may have an inflamed and exuding lepra vulgaris which 
looks like but is not eczema, and whose history is that of lepra plus superadded 
irritation and inflammation (not catarrhal). 

Fix>m eczema, ^atn«« and the thiece would be known at once by the micro- 
scopic characters of the scales and hairs. In lepra vulgaris, which is partial, 
there is never any secretion ; it is a primary form of disease ; there are no 
vesicles, the patch is thick, ci*acked, and covered by white scales ; the dis- 
ease affects )>eculiarly the ellK>ws and knees. Eczema lichenodes is the 
same as lichen eczematoiies ; it exudes very slightly ; the edge, however, is 
papular. As I have said, lichen agrius is considered by many to be eczema 
lichenoiles; in it the surface is not very moist; there are no vesicles; the 
secretion is not that of eczema ; there are no yellow crusts, but thick scales; 
and the surfiice beneath is rough and papular ; there is more or less indura- 
tion and thickening, and the etlge is markedly papular. I have no objection 
to unit« the two. 

Then eczema may be altered very much by secondary changes that increase 
in proportion to the chronicity of the disease. Eczema fi.ssum may appear to be 
identical with lepra vulgans, in which cracking is common : hypertrophy of 
the skin and subcutaneous cellular tissue (one or both together may follow 
an ecsema) ; in the one case we liave E. vernicosum, in the other E. spar- 
gofedfonue; in another case the tissues nuiy harden, in another ulceration 
may follow ; now in all the^e instances the history- of the case is our guide 
in determining the mixetl nature of the distsAst*. 

Then, lastly, eczema may cimipUoate and occur together with other dis- 
eases : with lichen^ scabii»3«, even lepra \*ulgaris ; and in such instances we 
have necessarily a Uending tof^ther of the characters of the separate dis- 



ECZEMA. 75 

eases. To remember the possible co-existence of diseases is one of the first 
necessities to a safe diagnosis. 

Hie Treatment, — Eczema I bold to be of the nature of a catarrJud inflam- 
mation. Tliis implies debility. It is highly unsatisfactory to consult books 
about the treatment of eczema. One gets very little from them. I shall 
not follow the bad example hitherto set of gi'ving a general resumS of the 
action of remedies ; but I will try and depict what we want in practice. 
Kemedies are local and general, of course. Some of the slighter forms of 
eczema produced "by irritants, the action of the sun, friction, and injury, 
readily get well by the removal of the cause, and the use of topical seda- 
tives and astringents. But in the vast majority of cases we require to give 
internal remedies to correct vicious nutrition, or some influence that debili- 
tates, and so cripples, the restorative power of the system directly, and the 
reparative action of the tissues indirectly. Acute general eczema does not 
give us much trouble : salines and aperients to counteract the pyrexia, and 
vegetable bitters presently, with ammonia, or the mineral acids, with the 
use of zinc ointment or lotion, do all that is required. It may chance, how- 
ever, that the patient is a stnimous or gouty subject, or suflers from nervous 
depression, or has been overworked : the indications here for appropriate 
treatment are obvious enough : cod-liver oil, colchicum with alkalies and 
ammonia, rest, and nux vomica or quinine, or iron (if ausemic), soon aid 
and consolidate Nature's cure. But in the more ordinary forms of eczema 
it is the physician's duty to search carefully for flaws in the health of the 
patient, especially in regard to his assimilative functions. The treatment of 
eczema can never be a stereotyped one. In the infant, cod-liver oil and 
steel wine are called for by the pale, pasty, lymphatic aspect of the little 
patient ; and how rarely do they fail in effecting a rapid cure, provided the 
food be attended to and properly prescribed. The one great fault is pov- 
erty of the nurse's milk ; and whilst we lay stress on medicine, we must not 
forget the prime importance of influencing the child through the natural 
means. Mothers, if need be, must take tonics, more animal food, fresh air, 
proper rest and quiet, and keep free from anxiety as far as possible. If the 
child is being " brought up by hand," " corn-flour " and other purely starchy 
compounds, I think, should be avoided. Fine-baked flour, and milk, with 
" wheat phosphates," is perhaps the best compound. I only speak as I have 
experienced. And going on to a later age, the same remarks apply in regard 
to remedies. The patient must be treated according to his or her dia- 
thesis and special nutritive wants and failings, and not the name of the 
disease. 

Then the sanguineous must take aperient tonics. I know none better 
than a mixture composed of sulphate of magnesia, sulphate of iron, dilute 
sulphuric acid, tincture of orange-peel, and some carminative. Of course 
the dose is to be regulated according to the aperient action of the medicine. 
But in adults wo may discover a dyspeptic state, gouty tendencies, and 
loaded urine ; in these instances, cutting ofl* beer and spirits, colchicum, 



76 ECZEMA. 

purgatives, and then tonics — t.c., vegetable bitters and alkalies — ai'e indi- 
cated. In eczema rubrum, aperients and tonics combined act best. In a 
very large number of cases, in persons of middle age, especially in hospital 
practice, one sees at once that bad living, hard work, and anxiety have 
prostrated the eczematous patient; under these cii'cumstances good food 
and (|uiuiue cure. In the better ranks of life, dyspepsia (pyi-otic, atonic, or 
irritable) are at the bottom of the mischief; luxury has entailed torpor of 
the secreting and assimilating functions: bismuth, soda, pepsin, mineral 
acids, or strychnine, as the case may be, are now available, and do good ser- 
vice. In ladies who have uterine mischief, iron and the like are called for. 
In all the chronic cases in which scaliness is the main feature, arsenic is 
serviceable. I am not disposed to extol the vii-tues of arsenic to so large an 
extent as is the fashion. It is a valuable remedy in eczema, but by no 
means a ^>a//r/cea. I find in the scaly cases, in which the health is seriously 
impaired, it docs good ; but I know it also does harm when pushed beyond 
reasonable limits, and I regard it as positively unjustifiable to give coui^ses 
of the drug for two years or more. In chronic eczema, with marked infil- 
tration and induration of the skin, a mild course of bichloride of mercury 
with bark is of infinite sei-vice ; and I fully agree with Dr. Frazer on this 
point. My maxim is, treat the patient as well as the disease. So vaiied 
are the deviations from health, that it is impossible to give more than an 
indication of the line of procedure in eczema, taken as a whole. I would 
refer lastly to the value of purgatives and diuretics. In eczema, esj^ecially, 
purgatives are of use ; they may act, and do, as derivatives from the skin, 
where discharge; is free, and in all the more seiious and inflammatoiy forms 
they should be given in conjunction with tonics. In the same way diui*etic8 
are useful over and above any general alkaline action they may have. 

TjOcoI Treatment, — If there be one thing moi-e necessiiry to iini)ress upon 
the minds of students, it is this ; that the skin of an eczematous subject is a 
very sensitive and irritable one, therefore the main i)lan of treatment, as 
far as local measures ai'e concerned, is to soothe and to allay irritation. In 
a large number of instances, local remedies suffice for the cure of eczema. 
The routine is to use either zinc or some mercurial, or other irriUiting, oint- 
ments, and I believe that in a good proportion of cases the disease is made 
worse by the use of irritants. In acute general eczema the hypenemic cutis 
is, as I have said, very sensitive, and the disease being injlammatory, we 
must rest ^jyrotect^ and soothe/ this is most important in the cnohttivfi^viud less 
so in the scaly stage. And other guides are the sensations experienced by 
the patient — the feeling of burning should make us very cautious in the 
use even of stimulant remedies. Water-dressing is useful at the outset, 
but the best plan if there is much swelling is to lightly bandage with a 
lotion containing a fair quantity of liciuor plumbi ( 3 ij ad 3 vj), or a lotion 
made of calamine powder 3 j, oxide of zinc, 3 j, glyceiine 3jss, water to 
3 vj, this being used very freely so as tp keep the surface moist, and ex- 
clude the air if possible. If the itching or sensation of burning is bad, 



ECZEMA. 77 

poppy fomentations, cyanide of potassium ointment (gi\ iij vel gr. v ad 
3 j), chloroform, wine of opium, and belladonna lotions, are useful. A very . 
convenient application is an ointment containing an ounce of elder-flower 
ointment, rubbed up with 3 jss of liq. plumbi and 3 j of vinum opii. In 
the second or exudative stage it is the custom to employ ointments, but I 
generally, indeed always, avoid them ; in proportion as the heat or itehing, 
the redness or swelling disappear, do I employ astringents, but whenever 
there are signs of irritation 1 use soothing and emollient remedies exter- 
nally — borax, carbonate of soda, and lead lotions are as good as any, and 
these in connection with aperient tonics generally, control the discharge, and 
I follow this plan even where the eczema is pustular. It is almost unneces- 
sary to add that the diseased parts should be most gently handled at all 
times. Soap should not be used, and no fiiction with the clothes allowed. 

When the third or scaly stage is reached, I believe it is often still highly 
necessary to avoid the use of any applications which act as irritants ; I 
mean that induce continual smarting, serous exudation, or increase the red- 
ness and the indui-ation of the diseased patch. There is a good deal of lo- 
cal (tissue) debility left behind in eczema, and irritability/ is one of the diief 
cliaracteristlcs of the skin of an eczematons subject. 

Astringents are generally called for in simple forms of eczema — such as 
we see in the scalp. I prefer, in connection with tonics, the use at the 
outset of, borax 3ii, acetate of lead gr. ij, and glycerine 3 j, to r j of lard ; 
a stronger ointment is 3 ij of ung. hyd. nitratis, 3 ij glycerine, and adeps 
3 ij. In some cases the ammonio-chlorido of mercury ointment acts very 
efficiently. Where thickening and induration finally remain, these may be 
regarded as secondary and ordinary results of congestion, and should be 
treated accordingly by revulsives. I often use a strong solution of nitrate 
of silver (3ij), in nitric ether ( 5 j), ointments made of the pyroligncous 
oil of juniper ( 3 j vel 3 iij a-^ 1 j adipis), or should that not suffice, iodide 
of mercury ointment (gr. v-xv to 5j). I cannot say that ** English skins" 
bear satisfactorily the " tar treatment " of Hebra ; by adopting it I have 
often disgusted my patient, and am not disposed to push it in future. The 
above line of procedure holds good in the case of children ; but here in ad- 
dition an absorbent powder is serviceable. It may be made of oxide of zinc 
and calamine powder and starch in equal parts. I prefer a lead or calamine 
lotion with exclusion of air, and at night a layer of elder-flower ointment, 
to anything else as simple applications in eczema infantile. 

The calamine powder I speak of is not that of the shops. None should 
be used save that which has been repeatedly washed, and very assiduously 
rolled or ground to an impalpable powder, otherwise it acts as an (gritty) 
irritant. When eczema is general, other local measures ai-e called for, and 
foremost amongst them stand alkaline and gelatinous baths, separately or con- 
jointly, if there is very much '* soreness." Carbonate of soda four ounces, 
and three pounds of clarified size is that I most usually order in the early 
stages ; in other cases, where the irritation is great, a " size " bath may 



78 POISON-VINE EEUPTION. 

even be advisable. Where there is free ^^ discharge/' and the patient is 
much distressed by the heat and irritation of the surface, we may make a 
thinnish paste with common whitening, and paint the surface freely o^er 
from head to foot, if necessary night and morning, taking care to keep the 
body as cool as possible in regard to the bed coveiings, whilst seeking by 
aperients and diuretics to relieve the discharge, and *' determine " it else- 
where. In the pustular forms, a strong borax lotion is my favorite, in 
conjunction with a weak citrine ointment. I repeat that in the disease which 
Willan called eczema, the plan is to soothe as much as possible. Authors 
have spoken very highly of certain plans which are based upon a different 
mode of action, but I suspect that this arises from the fact that lichenous, 
psoriatic, and pruriginous diseases have been regarded as eczema. It seems 
to me that one main argument in favor of the isolation of the " catarrhal " 
form of inflammation of the skin, under the term eczema, used in a limited 
sense, is to be found in the success of an emollient system of treatment, 
which is of little use in other diseases supposed to be stages of an eczema, 
in a much wider sense. Lastly, there is one exception to the rule here laid 
down in regard to the use of stimulants, and it is the case of eczema sec- 
ondary to scabies. Here the scabies must be treated and cured at all haz- 
ai'ds, and then the eczema will probably vanish, at all events by the use of 
the simplest remedies after the specific treatment for scabies has been fairly 
employed. 

Impetigo, see Pustular Diseases. 

For special i*emedies, see selected formulae, Nos. 32, 33, 34, 46, 48, 49, 
60-2, 64-9, 86-7, 123-6, 129, 146, &c. 

POISON-VINE ERUPTION. 

" The common poison-vine [Rhus toxicodendran)^ a species of sumach, and 
one or two other plants more rarely, cause, by contact, in some persons, an 
inflamed vesiculai* eruption of considerable severity. The hands and face 
are its most common localities ; but it may come out on the lower limbs or 
about the anus and genitals. Its duration, when severe, may be from one 
to two weeks ; but it is often quite limited and of shorter course. 

'' In the treatment of this annoying but not dangerous attack I have had 
a good deal of experience in my own person as well as with othera. I have 
found the most relief, and the greatest effect in shortening the course of the 
disease, by reducing the inflammation, from lead-water, ^arly, freely and 
frequently applied, with a large camel's-hair pencil. It should not be put 
upon the opened vesicles, which it irritates ; but around them, upon the 
reddened skin. In the practice of my brother, Dr. E. Hartshome, a very 
successful remedy has recently been the fluid extract of eerjjentaria, paint- 
ed directly upon the eruption. It seems to kill it at once." — Dr. Harts- 
home, Essentials of the Principles and Practice of Medicine, p. 354. Phila- 
delphia, 1868. 



CHAPTER IX. 

PLASTIC INFLAMMATION, OR LICHEN. 

WiLLAN included under the teim Papulae three diseases — lichen, strophiUus, 
and prurigo. In all of them are found litble solid elevations of the derma 
(papulie), generally about the same color as the skin, scattered or collected, 
feeling harsh and solid to the^ touch, and attended by itching. In the case 
of prurigo, these elevations are known to be the direct result in some cases 
of a disorder of the nei*vous element of the skin ; they are often accompanied 
by symptoms of atrophy of the skin, and marked signs of nerve paresis. 
Hence this affection is most properly transferred to the class of neurotic 
diseases. In lichen and strophulus the papulation is supposed to result from 
active inflammatory action in which the blood and tissues are concerned (a 
fibrous or plastic inflammation), constituting the primary and main disease. 
The papulation of true lichen is accompanied by dryness, more or less rough- 
ness, and general thickening of the skin. There is never any " discharge ; " 
lichen is not a *' discharging '^ disease, and in this respect differs altogether 
from eczema ; it is due to the effusion into the skin itself of plastic lym{>h. 
Strophulus is considered to be the lichen of children, but I shall have 
occasion to deny this, and to state that it is a mixed disease. However, at 
examinations candidates are required to say that strophulus is the lichen of 
infants and young children. 

LICHEN. 

This disease is essentially chronic and non-contagious, characterized by 
the appearance of little papules, about the size of millet-seeds, slightly red, 
or of the same color as that of the skin, distinct from, though close to, each 
other, at other times closely grouped. The former distribution is often seen 
on the inner, the latter on the outer aspect of the limbs ; the papules feel 
hard and cannot be removed by pressure ; if they are scratched, a little dear 
fluid may ooze out. The skin generally is dry and thickened ; there is con- 
siderable itching. Once formed, the papules undergo little change until their 
diappearance ; but then scales form upon them, and they are dry, very fine, 
and grayish. The disease has a great tendency to recur, to chronicity, to be 
complicated by other forms of disease, and to spread from one i*egion to 
another. It may be acute or chronic. Its seat may be limited, or absolutely 
general ; it exhibits, however, a predilection for the back of the forearms 
and hands, the lateral parts of the neck, and the face. As before observed, 
some think lichen merely a stage of eczema (especially Hebra and Hardy). 

lichen may be divided into {a) simple Or uncomplicated, and (6) compli* 



o 


« 


3. 


(( 


4 


a 


5. 


(( 


6. 


« 



80 LICHEN. 

cated or mixed. In the latter group the characters of other diseases — urti- 
caria, purpura, or eczema — are added to those of orduiary lichen. 

Simple or uncojnjylicated. Complicated or mixed, 

1. Lichen simplex. 1. Lichen urticatus. 

circumsci'iptus. 2. " lividus. 

gyratus. 3. " eczematodes. 

agriua. 

pilaris. 

tropicus. 

Under the head of lichen, Hebra includes two forms of lichen, named 
respectively, lichen rubra and lichen scrofulosus, to which special reference 
will be made. 

Lichen simplex is often seen in the summer, sometimes recurring in the 
same person several times ; the papules are red, smallish, and more or less 
pointed, lasting a week or so, and followed up by the development of others; 
they are usually seen on the back of the hand, the outer aspect of the fore- 
arm, the neck, and the thighs : thei^e is a good deal of itching. This form 
may last for weeks and months. The disaj)pearance of the papules gives rise 
to a little desquamation. The skin generally is dry, thickened. X. ctrcwm- 
scrijHus is present when the papules are collected together into little round 
or roundish elevated patches ; the bordier is well defined and papular, the 
surface elevated, rough and dry to the feel ; its area increases by circumfer- 
ential enlargement, and its centre presently clears somewhat ; there are gen- 
erally several circles, and their most usual situation is the back of the fore- 
arm or the hip ; at other times the back of the hand or calf may be affected. 
Tlie patches after a while get more or less scaly, or inflamed and cracked, 
simulating eczema, or in consequence of the centre healing, assume a circin- 
ate form ; but the history, absence of moisture, and the dry red base of 
derma, are distinctive. When several patches run together and form bands 
as it were, the disease is named Uchsn gyratus (Biett) : this is nothing more 
than the coalescence of several circles of lichen circumscriptus. 'Lichen 
a(/rii(s, or tlie inflamed form of lichen, differs from the above in the presence 
of secretion, and hence approaches eczema ; but it is, as its name implies, an 
acute inflamed lichen. It commences with fever, more or less marked, head- 
ache, pains in the limbs, stomach derangement, and the like ; some of these 
may l)e absent. Tlie local manifestation consists of clustered or closely- 
packed red impulw, accompanied by intense itching and burning, causing the 
patient to scratch violently ; tliLs in its turn sets up additional irritation, 
the torn and excoriated papube are inflamed, and exude a thin fluid ; the 
whole patch thickens, fissures, and becomes covered over with thin scales^ 
not the yellow puriform scales of eczema. Lichen agrius may also aiise by 
inflammation of the chronic stage of any of the other fonns of lichen, not 
primarily as an acute form. The acute state is about ten or fifteen days in 
duration, the chronic weeks or months : this variety of lichen is observed 



LICHEN. 81 

about the back, neck, legs, arms, and shoulders : it constitutes one aspect of 
grocers', bricklayers', and bakers' itch. Vesicles and pustules may however 
form ; and then we have an inflamed, raised, reddened, excoriated, discharg- 
ing, fissured patchy the seat of intense and often intolei*able itching and burn- 
ing, made worse by stimulation of all kinds, especially the warmth of bed. 
This is no doubt a mixture of eczema and lichen, and is rightly termed eczema 
lichenodes or lichen eczematodes. The disease either subsides or increases by 
the development of fresh crops of papulj©. In time lichen agrius, the papules 
form the prominent feature. True lichen agrius, then, ia an inflamed lichen ; 
but the co-existence of lichen and eczema in one and the same patch closely 
simulates it. 

lAchen Pilaris, — Much dispute has arisen in regard to this variety. Oc- 
casionally one sees, either alone or in conjunction with ordinary lichen, lit- 
tle elevations like papulie, which are however seated at the hair follicles ; in 
fact, the hair pierces the centre of the papule. A distinct alteration is felt 
by the finger. There is no doubt but that hyperemia of the follicular plexus is 
followed by fibrous deposit outside the follicle, forming a papule. There is 
no reason why in ordinary lichen this should not happen, in the same way 
that hypersBmia and enlargement of the sebaceous follicles is seen as an acci- 
dent and accompaniment of scabies and other diseases. Indeed any irrita- 
tion may induce this " lichen pilaris," and it is sometimes seen in chronic 
scabies. Generally the papulation involving the hair follicles is slight, but 
I have seen it take on a very exaggerated form in the leg, the eflusion of 
lymph producing hard, large flat papules, nearly the size of split peas, per- 
forated in their centres by hairs. In the last case I had under my care, in 
consequence of the number and close packing of the papules, there was a 
patch over the whole inside of the leg from below the knee to about three 
inches above the ankle : on the other limb the disease was not so far ad- 
vanced ■; each papule was covered by what appeared to be a largish adhe- 
rent scale. This was made up of epidermis cells. The patch was elevated 
sensibly, felt dense, and was dark -colored. I have seen other cases of the 
kind. There was in one case severe, and in a second scarcely any, itching. 
It might well be called lichen planus, but diflers, as wp shall see, from lichen 
ruber of Hebra, which is not seated solely at the follicles. Lichen pilaris 
then is " fibrous inflammation " seated at the hair follicles, the efliision of 
plastic lymph taking place around the follicular walls, and producing, accord- 
ing to its degree, more or less well-marked and distinct papulation, each ele- 
vation being perforated by a hair. It must not be confounded with pity- 
riasis pilaris, which is merely a desquamation of cuticular cells into, and dis- 
tending, the hair follicles, preventing the formation of the hair, and produ- 
cing a blocking up of the follicles, the collected cells forming ** a knot " in the 
upper part of each follicle, and constituting in scrofulous subjects what He- 
bra describes as lichen scrofulosus^ a distinct form of disease which, accord- 
ing to Hebra^ shows itself by the appearance of little elevations, about the size 

of millet seedsy either pale, or yellowish, or brownish red, never vesicular; 
6 



82 LICHEX. 

always grouped, sometimes in circles or segments of circles. The parts which 
have been papular after a while appear to be covered with a number of little 
scales ; the patches itch slightly, but not being scratched, are not excoriated 
nor discolored by blood. These patches remain in* the same stat« for a long 
time, and undergo no further changes than exfoliation and involution. The 
disease is limited to the trunk, the belly, the bi'east, and back, being rare 
on tlie extremities. The course is very slow ; generally speaking the groups 
are developed at the same time, i*eaching their height in a little while, and 
then remaining in stcUu quo. Oftentimes, in consequence of the absence of 
local symptoms, the disease exists unnoticed for some time. When at its 
acme, other symptoms are observed : between the groups, and at the same 
time, on parts free from lichen — that is, on the extremities and face, more 
or less nimierous isolated bluish-i*ed elevations are develoj>ed ; these are 
about the size of lentils, and look very much like common acne ; some are 
said to contain pus, then by-and-by they wither and disappear, leaving daiic- 
ly pigmented orbiform, lentil-sized marks in some places, whilst in others 
fresh formations take place. The skin between the diseased patches is the 
seat of desquamation, the scales being pale and shining ; thus the whole skin 
assumes a cachectic appearance. In 90 per cent, it is observed in markedly 
scrofulous subjects, with swelling of the submaxillary, cervical, and axillary 
glands, with caries and necrosis, or tabes mesenterica. In no case is there 
lung disease. Hebi*a has seen many cases, and all recovered. It is not 
phthisical pityriasis. As to patholog}', each knot or papular elevation is 
seated at the oriiice of a hair follicle, and is made up of epidermic scales and 
fatty matter, in the form of fatty nuclei within the cells. The disease is 
seen almost exclusively in males, between the ages of fifteen and twenty-five. 
Tlie treatment is cod-liver oil internally and extei-nally. This disease is not 
a lichen. There is no inflammatory effusion outside the follicle, but accu- 
mulation of epithelium and fat inside. It is a pityriasis pilaris, and diflferB 
in no way from that disease wliich will be described under pityriasis, save 
that it occurs in strumous subjects, and is in consequence all the more severe. 
The fatty matter given out by the sebaceous glands is more abundant, and 
the acrio-like spots are readily accounted for by the blocking up of the hair 
follicles into which the sebaceous ducts 0|>en, and the resultant infiammation, 
favored by thq diathesis : the cicatricial marks left after the disappearance of 
the acne spots being due to atrophy, which is one of tlie most usual eventB 
in struma. Tlie cui*e by cod-liver oil is one of the strongest argiimenta in 
favor of this view. 

Lichen ruber is really, as fur as I know, a true lichen, but I am not cer- 
tain tliat the disease occura in this countiy, save to a slight degree. Ac- 
cording to Hebi-a it has three stages: — 1. In which are papules, millet 
size and discrete, covered with fine scales, not .clustered, not irritable, and 
therefore not scratched and excoriated ; not general, but confined to one 
part, mainly the limbs, keeping their original size and not themselves en- 
larging. 2. In which a patch is formed by the springing up of new papules 



LICHEN. 83 

in the intervals of the old ones, the ])atch being dull-red and covered with 
scales. 3. The whole skin gets red and papnlated, and at length cachectic ; 
it desquamates in flakes. The nails become brittle and thickened. There 
is not much itching. The whole skin thickens and cracks from the muscu- 
lar movements, and what is of importance as effecting the determination of 
the nature of the disease, this latter state affects especially the palms of the 
bands, soles of the feet, besides the Angers and toes. '^ On examining 
thin sections of the skin with the microscope, the chief morbid change which 
has been discovered is in the root-sheaths of the hairs. As is well 
known, the root-sheath, in its normal condition, is a cylindrical tube, 
surrounding that part of the hair which is embedded in the skin. In 
eases of licf^en ruber it is changed into a funnel-shaped body pointed 
below, expanding towards the mouth of the sac, and looking as if it were 
made up of several hollow cones, loosely included in one another, and having 
the hair in the middle. Besides this, the cutaneous papillse have been 
found to be enlarged, and the vascular loops which they contain to be di- 
lated in this disease." When the disease becomes chronic, emMciation, and 
a state of marasmus set in, and these are followed by the patient's death. 

lAeJien tropicus, or ** prickly heat," is generally described as an eruption 
of numerous papillao of vivid-red color, about the size of a pin's head, with- 
out redness of the skin generally, often interspersed with vesicles and ac- 
companied by a peculiar tingling and pricking sensation, which may be 
almost intolerable, and is excited and intensified by heat, warm diinks, 
flannel, &c The disease mainly occurs in hot climates, and attacks the 
parts covered by the clothes, the arms, legs, breast, thighs, flanks, and the 
upper part of the forehead. It sometimes occurs in this country. On one 
day, the 21st of July last, duiing the unprecedented hot weather which 
prevailed, no less than seven cases came under my notice in the skin de- 
partment at Charing Cross Hospital. Now the disease is mostly regarded 
as a lichen. I cannot subscribe to this opinion. No doubt acute lichen 
is produced by intensely hot weather very frequently, but as far as I have 
seen lichen tropicus, that disease in which '^ pricking," burning sensations 
are marked — and many cases came under my notice in Syria — the anatomi- 
cal seat of the disease is the perspiratory follicles ; the great demand made 
upon the perspii'atory glands deranges their circulation, so much so, that 
they are mostly unable to excrete sweat ; the result is that the surface is 
not properly cooled by evaporation, the sweat products are retained, and 
consequently the nervous plexus of the skin is acutely disordered : hence 
the bumingy pricking sensation. Here and there over the surface, a cer- 
tain amount of pei*spiration is produced ; this collects beneath the cutis and 
forms vesicles. It is not uncommon to find lichenous papules intermingled 
with those of prickly heat, and even enlarged sebaceous follicles ; these 
are accidental, the result of the disorder of the circulation. I should there- 
fore take lichen tropicus away from its present position, and place it 
amongBt the disorders of the perspiratory glands. To recapitulate. Under 






84 LIOHEH. ^M 

Group 1., or iincom|ilicttted lichen, I rank lichen simplex, ctrcnmscri^fl 
gyrstus, agrius, pilaris, ruber, transfening Ucheu scrofulneus to pityriM 
piliu'ia, and lichen tropicus to disorders of sudor! parous glands, nnd tki 
leads niBj before noticing the second group — via,, mixed or compUoated' 
lichen, to Mpeak of the 

PaUuJtgy. — Now one of the broad iliKtinctions between lichen and 
is the entire absence of discharge in the former and its presence 
Very many different ojiinious have been lield as to their anatomical seatn. 
lias been said that the little solid elevations of the skin which 
are seated at the sebaceous glands ; others affirm that they are due to hjper- 
leniic follicles, ^\-ith subsequent efTusiou ; others tliat thej are enlarged 
papula of the skin. Now in some cases, where chronic irritation exists, it is 
very common to see congestion of the sebaceous follicles, as in scabies } in 
others the follicles become inflamed and prominent. These conditions give 
rise to flevations that look like pajmlie, but they differ from the hard, pale, 
or sliglitifd papulw of true lichen, which is produced by an effueion of 
plaAtic lymph into the skin, eB]>ecially its papillury layer ; and this effusion 
is not limited, but is genei'al, so that in well-marked coses of lichen the wliole 
integument is dry, harsh, discolored somewhat, tougher than usual to the 
feel, contrasting strongly with the thin, light, delicate skin of mi eeaemstons 
subject. Ar far as microacopic examination has gone this has been shown 
to be true ; the vessels of the papilta> may be dilated, the jifipillw tbemselvM 
hyiiertrophied. liven in lichen the irritation set up induces turgeac«nc« of 
the sebaceouB and other glands, especially in lymphatic subjects: but these 
phenomena are only accidental to true lichen. It will now be seen why I 
regard lichen scrofulosum and lichen tropicus as misnamed and misplaced. 
I am not prepared to say the relative degiee in wliieh the vascular aod 
nervous pupillw are involved in lichen. And now I speak of Gi 
mixed forms of lichen. There are thi-ee diseases here : L. ni-ticatus, la, 
lividiiu, and I.. ecieraatodeB. The latter has been referred 
bead of lichen agrius. 

Ziehen vrtiealiiji is simply lichen complicated by urticaria, described 
dally by Bateman, confined to children, and of special obstinacy. 
ally described as resembling the bite of bugs, but more proiierly as consist- 
ing of iMpuiBB, which are larger than usual, Kurrounded by redness, uid 
intermingled with wheals here and there. In consequence of the scralching, 
the jioinls of the pB])ules are torn :ttt and a litth) dark Bi>eck apjiears, so that 
the papules are more or lew pruHiEinous, In other instances the papules 
themselves are a compromise, as it wer«, between the two forms of eruption; 
there are smallish, white, fugaciomt elevations in conjunction with an ini- 
table itchy akin ; and generally pruriginoiis papultB are preKent. Tlio disoaae, 
it is highly importaut to observe, may attack the feet. In other instances tlto 
pnpuU is developed outof an urticat«il spot ; so that in all instances we may 
trace tlie composite charuc««r of this variety of lichen. The wanuth of the 
is partiuuUrly distressing in augmenting tie itching. When the diseoae 



I,, or 
;eiie^ | 



ebed J 



LICHEN. 85 

some time, the surface is thickened, dirty, so to speak, and dry. It is com- 
mon in the middle months of the year (summer and late spring), and scabies 
is often at the bottom of it, and its original excitant. 

JLichen lividus is lichen in conjunction with purpuric spots. It is seen in 
those of ill-health, in the intemperate and badly-fed, especially about the 
legs, where gravitation comes into play. The development of the papula; is 
accompanied by a little hasmorrhagic effusion, and this may take place at the 
exact seat of the formation of papulae, or elsewhere : hence we may have as 
separate existences, hard, livid, flattened papules ; or ordinaiy papules with 
pui'puric spots — a mixed, not a confused eruption. The characters of ordi- 
nary lichen may be seen elsewhere — on the arm, for instance. 

I^rogn&sis is not grave. Lichen circumscriptus and lichen agiius are often 
very obstinate, so is so-called lichen pilaris and lichen occurring on the face. 
As a rule, the simple forms get well, with proper treatment, in two or 
three weeks. 

Causation is supposed primarily to be due to the existence of a peculiar 
(dartrous) diathesis, but of which I know and can comprehend notliing. 
Lichen appears to be most apparent in the nervous temperament in summer- 
time. It attacks all ages, and is evoked by local and reflex irritation, by a 
deficiency of alkali in the system; irregularities — mental, physical, alimen- 
tative, etc.; hereditary tendency; certain occupations — e, </., cooks, bakers, 
grocers, bricklayers, etc. ; by hot climates. Similarly in this as in other 
diseases — a predisposition to disease shows itself by tangible evidence when- 
ever any determining cause unbalances the resistant power of the system. 

Jhafffuma, — There are some difliculties here. The chief points to re- 
member in regard to lichen are the dry and thickened state of the skin, the 
presence of papules, which are always to be found, if the disease is in 
patches, at its extending edge, their hard feel to the touch, and their tin- 
gling or itchiness. Lichen simplex and scabies may be confounded. Z,ichen 
is uniform, scabies multiform. In scabies, besides papules there are vesicles, 
often pustules, and the papules are not so closely aggregated ; the eruption 
also is in the line of flexion, not, as in lichen, in that of extension — e, (/, 
lichen is seen chiefly on the outer aspect of the arm ; it may occur on the 
back of the hands and fingers, but it is not interdigital. Lichen never, ex- 
cept in its urticated variety, occui-s in the feet ; it is common on the face ; 
scabies is not. In scabies too we find the chai^acteristic vesicle and sillon ; 
then the disease is contagious and easily removed by sulphur treatment. 
It is also seen in the seats of pressure, rarely above the level of the mamma, 
and not associated with the peculiar dry, harsh, thickened state of skin as 
lichen. 

Zfichen urticatus closely resembles scabies, but the einiption differs in the 
evanescent character of some of the spots (urticaria), in the absence of ve- 
sicles, of pustules, etc. ; in its presence, oftentimes, about the face, and its 
general absence from the feet ; for it is very probable that when it attacks 
the feet, L. urticatus is complicated by scabies. In the chronic condition, 



86 LICHEN. 

tlie papular aspect of the rash, with the peculiar hard solid feel, and brown- 
ish aspect of the papulsB, will at once be distinctive. 

l^rnrigo may simulate lichen, but prurigo is associated with an iinhealthj, 
relaxed, muddy, dirty state of the skin, — flabby is the word ; the papules 
(which are pale) are fewer in number, and each is marked at its apex with a 
dark black speck (dried blood), effused as the result of scratching. The 
skin is not thickened and dry, as in lichen, nor is there any attempt at 
scaliness, as in lichen, nor aggregation of papules into patches of groups. 
Pi-urigo is essentially a disease of advanced age ; pediculi are mostly pres- 
ent, and there is often a peculiar urticated state of skin, seen v^ry markedly 
on the back and chest, produced by an exaggeration of the spaces enclosed 
by the normal furrows. Prurigo is not cotnmon about the face-; the sen- 
sation is one of formication, and is altogether out of proportion to the 
local disease, whilst pediculi may frequently be ' detected in the folds of 
the linen. 

Lichen agrius resembles eczemay but the latter is moist and discharging, 
occurs in delicate and thin, not in harsh dry skins ; again, the history and 
edge of the patch in lichen point to the existence of papules ; then the 
patch is much thicker and harsher than in eczema, and wants its thick yel- 
low crusts : the latter in lichen are thin, pretty few, and " flimsy." Chronic 
eczema never gives rise to such a thickened condition as lichen. 

lAchen circufasciiptusy with its papules, ought not to be confounded with 
the vesicular or furfuraceous herpes circinatus, in which a parasite is found ; 
nor with lepra wlgai^^ which is entirely devoid of discrete papulie, and 
presents })eculiar whit« imbricated scales, and as its selective seats, the 
|)oints of the elbows and knees. 

It is important to remember thai scabies may be complicated with lichen^ 
and tlie latter may be set tip as the result of irritation of scabies. One sees 
this state of things very frequently in the hot season — the irritation of a 
few scabious spots bringing out a pretty general lichen. 

Treatment. — The early stages of lichen, when accompanied by febrile 
symptoms, may be treated ui>on general principles. Salines, aperients, 
tepid baths, to which may be added bi-an, gelatine, size, and the like, are 
pro|)er. In lichen agrius poulticing, rest, and lead lotion, or an ointment 
containing watery extract of opium, lead, and adeps. To allay itching at 
this stage, besides the baths, ointments of cyanide of potassium may be used 
in the proportion of three grains to an ounce of lard ; oxide of zinc, borax, 
of each a drachm, camjihor ten grains, and adeps one ounce ; or bichloride 
of mercury or borax lotion. Then, when the disease has passed the acute 
stage, we must treat the patient according to his constitutional bias. In a 
goodly number of cases we shall note that he or she is over- worked, worried, 
not taking sufficient food and rest, is annoyed by dyspepsia, and is looking 
thin and anxious. In such cases a change from depressing and over-work, 
the correction of acid or atonic dyspepsia, mild aperients, and a course of 
mineral acids and bitters, will speedily be effectual, the local treatment 



STEOPnuLus. 87 

consisting in the use of mild astringents — zinc and dilute nitric acid 
lotions. 

In other cases, where the urine is loaded, and the skin generally is dis- 
colored and harsh, alkalies are of sei-vice, and may be given with ammonia 
and bitters, together with alkaline baths and borax lotions. In other cases 
it is a][^)arently impossible to say that anything beyond general debility 
exists ; under such circumstances ai*senic is to be employed. In lichen cir- 
cumscriptus again, an alkaline course is beneficial, and if there be any ten- 
dency to rheumatism bromide of potassium may be given in addition ; and 
in lichen agdus gouty tendencies must be met by colchicum. In the former 
variety of lichen weak mercurial ointment, the citrine ointment diluted 4 
or 6 times, or the ammonio-chloride (grs. v. to 3 j) or acetate of lead, iodine, 
iodide of sulphur, and sulphur ointment, according to the induration and 
chronicity of the patch, and in the latter variety i^aceration with glycerine, 
borax 3 j to ? j of adeps with glycerine, or ammonio-chloride of mercury 
ointments, and lastly, painting with a solution of nitrate of silveri or glyoeral 
tannin, are of use. 

When the disease is very chronic, and there is much thickening of the 
skin in general, and in lichen pilaris, a course of bicyanide of hydrargyrum, 
in the same doses as the bichloride, with bark, is necessary to cause re- 
sorption of the plastic material poured out into the derma ; and local stimu- 
lation to the skin with sulpliur vai)or baths may then be employed. But, 
indeed, no one plan can be laid down for lichen. Each patient must be 
treated according to his individual peculiarities — one man will need cod- 
liver oil, another steel, a third aperients, a fouHh arsenic, a fifth colchicum, 
and so on ; but the tendency should be in the early stage to use alkalies, 
and in the later stages arsenic. The too free and early use of stimulants to 
the skin should be avoided — emollients and alkaline baths being most fitting 
for recent disease. In all cases stimulants are to be dispensed with entirely 
if possible, and the food is to be unstimulating. A very good form of local 
application for itching is dilute hydrocyanic acid a drachm and a half. 
Brandish' s solution of potash half a drachm or a drachm, and six ounces of 
rose-water. Lichen lividus requires the free use of acids and bark, with 
good food. In lichen urticatus the presence of scabies must be very closely 
looked after. I have generally succeeded in curing this obstinate form of 
lichen by ensuring perfect cleanliness in the way of linen, giving diuretics, 
with occasional doses of calomel, cod-liver oil, and baths containing sul- 
phuret of potassium. See Formulse, Nos. 32, 33, 39, 41, 48-52, 58, 60, 72, 
106, 122, 124, 126, 132, 141, 146, &c. 

STROPHULUS. 

This disease, popularly known as the red gum, tooth-rash, white gum, or 
red gown, a ^^ papular '^ rash observed in children, is looked u]>on usually as 
the lichen of infiemts. It is a disease of acutish aspect, characterized by the 
appearance, on the most exposed parts, the face especially, but also the 



»6 B-l'BOPHCI.IJB. ^H 

Beck, tti'iDS, nnU liuilis, of Buccessive crops of little red, in-egulai-ly dispo^H 
or slightly uggi«gated, acumiitat«d ].)apules, intermingled with mon? or Ml 
erythemB, The papules vary in size from pins' heads to siaall milltrt HDH^a ; 
are attended with itching, sometiTiies slight moiBture, imd destfiianuitioii. 
There we several varieties, ae follows, according to Willan: — S. intcrtinc- 
tUB, confertus, albidus, candidus, volaticus ; and in addition, Hai-dy and Buia 
have dewrribed a mixed form under the name of H. pruriginosua. 

S. tHlerlinelui. — -lu this variety the [mpiilea are vivid i-ed, and seen about 
cheeks, forearm, and hack of hauds ; they lU'e especially characterized by the 
iutemiixlure of red blushes (erythema), and are int^rtinctured, in fact. 
It oecni-s ill young infants under three months generally, and lasts from two 
to four w<«ks. When the jiapujes ure numerous and closely packed — con- 
fliieut — the name S. eonfertus is used. There is less erythema here ; the 
papules are paler, the disease is of longer duration than the last, and a 
recurrence is likely. Tbia variety occui-s about the jjeriod of dentition, and 
in a chronic Rt«te is often limited to a few jiatches, which run through s 
slovr course, and leave the skin harsh and dry. It is also most common on 
the arm. 

S. volatleua is a term applied to the disease when it consists of small 
meral patches, made up of a dozen or ao of i)apulcs, the skin being somi 
hot and itcliy. This vai'iety isobserved about the aima and cheeks. P 
spring up here and there for two or three weeks. 

S. aibidtm is a misnomer. The name is applied to small papular 
tions, perfectly white, which make their appearance about the face and 
and are distentions of the little sebaceous glands of the skin. 

Tn S. eaiu/ului tlie papules are large and whitish ; they are seen intei 
gled with those of H. eonfertus ; appear about the shoulders, flanks, sai 
arms uf children about a year old, and disappear in seven or eight days. 
The above are all simple varieties. Tlie mixed form of disease presents, it 
ia aaid, the characlers of strophulus and prurigo conjointly, and is named 

StTophvltu prunginnmu. — This in a true lichen, in which the papules are 
prnriginous ; it is an obstinate form of disease, and a not very rare one. It 
occuro in young children from a twelvemonth or so to eight or nine yeara of 
age. Papules appear pretty genei-ally over the body; they are harsh, dry, 
discrete, not confluent ; some are surrounded by a red blush. TheHC {>api)lM 
itch considei'ably, are scratched, and then the apices become discoloi'ed from, 
the drying of a little exuded blood, as iu prurigo, but it is often only a very 
minute dark speck. After awhile the papules are coverwl by scaliness, the 
skin looks dirty and discolored, Ecthymatous pustules may result from the 
continued Bcrat4:bing. Tlie chief seats of the diseaae are tlie back and front 
of the chest, the amis, and the fuce. Tlie disease looks like v. dotting over 
a dry harsli surface by |iale papules with dark a]>iccs (|H-uriginouH). The 
disease is mostly chronic. It follows as a consequenee of uncleanliuess, bad 
living, the want of fresh air and projier ventilation in dwellings, and is fre- 
quently seen in hot weather. It in easy to conceive that tlie uutritloa irf 




8TEOPHULU8. 89 

the skin is veiy much below par, and that the disease is in a gi*cat measure 
due to a disorder of the nervous element in the skin. The disease is very 
uniform in its aspect. It is thought that the prurigo mitis of Willan may 
be this disease, which is better named lichen pruiiginosus than strophulus 
pruriginosus. 

Pathology and Cause. — It is often said strophulus and lichen are one and 
the same thing in essence, strophulus occurring in the delicate and vascular 
skin of infants. After adolescence the nutrition of the body has so far 
changed, and the skin has become firmer and less elastic, so to speak, and 
strophulus does not occur. It is also said in books that in children simple 
disorder of the stomach leads to blood changes, and this lA readily reflected 
on the skin, producing strophulus — ex., acidity, bad milk, teething. I can- 
not subscribe to this. The strophulus of authors is a mixed disease, in 
some cases a real lichen, in others a different matter. I believe that where- 
as the anatomical seat of lichen is the papillary layer of the derma, in what 
is often termed strophulus it is the sweat-follicles. The recent hot season 
(summer of 1868) has supplied me with a good deal of material, and in 
cases which have all the appearance in children of strophulus, the papillary 
elevations have been seen with a powerful glass to be seated at the sweat- 
follicles, and on viewing them in a slanting direction the central dark aper- 
tures of the pores were seen by the students. When we remember that 
in cases of strophulus the children attacked are those who are kept in heated 
rooms, or are muffled up from the fresh air — that the disease occurs during 
change of season, and on exposed parts — ^it will be readily conceived that 
the view I take of it may be the correct one. I think, therefore, that the 
simple forms of strophulus should really be ranked under the head of dis- 
orders of the sweat glands. 

In contrasting the papule of a lichen and strophulus, there is every differ- 
ence found : that of lichen is not removable by the finger, and it is solid 
feeling (exudation) and pale ; that of strophulus is vivid red (vascular), di- 
minishable by pressure, and softish to the feel. 

Diaffnosis.—rln strophulus the papules have an exanthematous aspect 
which is very significant. As a rule, they are not so dry and harsh as those 
of lichen, and the disease occurs peculiarly in infants ; it is not accompanied 
by a harsh state of skin, by crackings, or the formation of crusts ; it is more 
intermitting in its aspect than lichen. S. — or as I would call it, lichen — 
pruriginosus is recognized by the presence of lichenous and pruriginous pa^ 
pules together. In lichen, the papules are generally closely aggregated, and 
there is the muddy aspect of the skin ; besides, the disease is seated on the 
outer aspect of the limb, and the pruriginous papules are wanting. S. pruri- 
ginosus puts on a very close resemblance when pustules are present, as the 
result of irritation, to scabies ; but the history of scabies is not papular, but 
vesicular : it affects the legs and feet, whereas S. pruriginosus does not ; it 
commences in children often about the buttocks ; presents the characteristic 
yesicle and cnniculus; does not attack the face, as in S. pruriginosus. Scabies 



90 STEOPHTJLUB. 

a 

is sometimes ])niriginou8 ; but then it is so chiefly about the abdomen. It 
is the early history which clears up the doubt, for the ecthymatous pustules 
are the result in both cases of indtation — in one the strophulus, in the 
other the scabies ; and hence must bear much resemblance. If these sooond- 
ary manifestations are absent, the diagnosis offers no difficulty. 

Treatment. — In simple strophulus, deanliness must be observed; the 
child must not be too much wrapped up ; the use of soap must be avoided ; 
the child should have proper food ; the state of health of the nurse should 
be seen to ; local irritation — e, g,^ that of teething, hot clothing (flannel), 
must be remedied ; any aphthous state must be cured ; acidity should be 
corrected, and gentle aperients given ; tepid sponging, spirit or alkaline lo* 
tions may bo used locally. A very useful one is, carbonate of soda 20 
grains, rose-water G ounces, with 2 drachms of glycerine. Almond emulsion, 
Ume-water, and mild sulphur ointment may be also used. In the pnirigi* 
nous form of strophulus, we must place the patient under the most fiavorable 
hygiene ; give him good food, good air, plenty of washing ; and internally, 
iron, cod-liver oil, and quinine, or chloride of potash. See formulas for 
lichen. 



CHAPTER X. 

SUPPURATIVE INFLAMMATION OR PUSTULAR DISEASES — IMPETIGO CONTAGIOUS 

IMPETIGO — ECTHYMA — FURUNCULUS — ANTHRAX OR CARBUNCLE — MALIG- 
NANT PUSTULE — DELHI BOIL — ALEPPO EVIL — BISKRA BOUTON. 

In many very different diseases of the skin, pus is present, and if the term 
pustular were used m its very widest sense, a large number of diseases 
would have to be included within it ; for instance, acne ; parasitic diseases, 
such as favus and scabies; pemphigus; variola; farcy; varicella; and so 
on. But in these the presence of pus is, as it were, a- superadded phenom- 
enon ; it is not a primary or even essential condition, and it is thrown 
into the shade by the prominence of other features. In those affections 
which may more strictly be called pustular, the suppuration is the leading 
and the primary condition, that which we have to recognize and to remedy. 
Now under the terms pustular diseases, thus defined, are usually comprised 
impetigo, ecthyma, and fumncular affections — ^the latter term including 
furunculuB or boil, anthrax or carbuncle, and pustula maligna or malignant 
pustule. 

If we compare the two diseases, impetigo and fu/runctdua^ we note in the 
former that the disease is very superficial, does not involve the deep struc- 
tures, is rather sero-purulent than truly purulent, has no tendency to ulcer- 
ate, occurs in lymphatic subjects, and is accompanied by a slighter degree 
of inflammation and less amount of concomitant pain and heat. The ana- 
tomical seat is the rete mucosum and derma. In furunculus, the disease is 
deeper, there is more inflammatory action, there is more pain, more swelling, 
there is sloughing and ulceration, and subsequent cicatrization. In ecthyma 
there is cachexia, freer suppuration, but no " core," as in furunculus — ^that 
is to say, no portion of the skin-tissue sloughs. However, wha^ are called 
boils may occur together with ecthyma, which stands midway between the 
two groups. Now in fumncular affections the seat of disease is said to be 
the sebaceous glands. This Mrill be more particularly dwelt upon in speak- 
ing of furunciili. 

IMPETIGO. 

In describing eczema, it was stated that in some cases instead of the se- 
cretion remaining sero-plastic, it became charged with pus-cells, in fact 
sero-purulent or puriform. The variety in which this occurred is called 
eczema impetiginodes (pustular eczema). Now this purulent character 
may be assumed from the first, and then we have what is called impetigo. 
Most authors agree in regarding impetigo as a pustular eczema — an eczema 



92 IMPETIGO. 

occuning in a pyogenic habit of body. It may therefore rank with eczema, 
but I have placed it under the head of pustular diseases at present, in order 
that I may compare it with another form of disease which i^ like it, but of 
whose true position I am yet uncertain — I mean that form of disease which 
I have called impetigo contagiosa (contagious impetigo). But I will first 
describe what is generally known as 

Impetigo. — It is characterized by the presence of psydracious pustules, 
which are elevations of the cuticle, by small collections of pus: they run 
together ; the increased production of pus, sometimes at different points, 
augments the area of the purulent patch often to a large size. The pus 
is soon discharged by rupture of the cuticular wall and then dries into 
thickish yellow crusts, accompanied by more or less oozing. The disease 
then is an infiltration of pus beneath and in the deep layers of the cuticle ; 
there is of course hypersemia of the cutis. No.w when the patches are 
small and scattered, the disease is called impetigo eparsa (scattered) ; when 
it occurs in a large irregular -patch, T, Jigurata, When the discharge is 
free, and there is a heaped-up and thick crusting from the drying and col- 
lection of the secretion, it is termed I. acabida^ and occasionally the deep 
tissues are inflamed, and then we have I, erysipdatodea, t must say a few 
words upon each of th^se varieties. 

Impetigo figuraJUi, — After more or less pjrrexial disturbance, numerous 
pustules aggregate upon a reddish surface ; they run together, break in two 
or three days, and discharge a tenacious fluid, which at first is very much 
like ** concrete honey " (hence the name, Melitagra) ; presently becoming 
dry, yellow, discolored. The disease is generally observed on the face. The 
circumference of the patch is red, and exhibits fresh pustules ; several patches 
may coalesce ; the crops of pustules are successive ; the surface beneath the 
scabs IS red and superficially excoriated. It often become chronic, and may 
cover the entire face. When this is the case, the deep parts are secondarily 
inflamed and swollen. The size of the crusts depends upon the amount of 
secretion. When it is free, as in infants at the breast, the scabs may be *' sta- 
lactkic;^' hence also the terms crusta lactea, porrigo larvalis. The neigh- 
boring glands are swollen. 

I, sparsaj as I understand it, is nothing more than the above, in small 
and distinct spots. It occurs often over a wide area — the head, the lower 
limbs, and the trunk. 

J, acabuia is produced from either of the above varieties by the formation 
of thick large ci'usts. It is best seen on the limbs, as in a case some time 
ago under my care, where both legs were covered from knee to ankle with 
hard, dry, brownish, and thick crusts, covering over a red weeping sui*face 
beneath, like the " bark of a tree." 

In T, ergaipeUitOileSy the onset and march of the disease is marked not only 
by general but much local irritation — e. g,, heat, tension, redness, swelling. 

XfOcal varietiea attack the ear, the nose, the scalp, and face. It is usual 
to specify particularly I. capitis. This has received a host of names : por- 



IMPETIGO. 93 

ligo larvalis, tinea granulata, melitagra, cnista lactea, &c. It may be I. 
sparsa or I. figurata. The pustules are perhaps not so distinctly clustered, 
they are whitish, attended by itching, the presence of pediculi and swollen 
glands. The discharge mats the hair together into a compound, sour-smell- 
ing mass, beneath which the surface is red and tender. The sparse variety 
is the rarer. Children of strumous tendencies are attacked. 

Two other forms are described by authors, I, syco^iforme and Z acniforme. 
The former is really I. labialis, in which there is a good deal of swelling and 
tension, and the discharge heaps up into honey-like crusts, often just beneath 
the septum nasi. The latter is a suppurative inflammation of the hair fol- 
licles of the beard, and is often confounded with parasitic sycosis. But this 
impetigo of the beard is often an acute affection. There are im[)ctiginous 
spots about the fjEu^e outside the beard ; it affects quickly at the onset a 
large extent of surface ; it is more superficial than the parasitic vari- 
ety, has more crusting, the hairs in the follicle are not loosened or ren- 
dered dry and brittle, and there is no fungus present. The disease may 
become chronic. 

Pathology. — True impetigo is a suppurative inflammation of the skin, the 
anatomical seat being about the derma and the cuticle, at the basemeht 
membrane. Pustules seated at the hair follicles may be, as before observed, 
not impetiginous. 

Causes. — Impetigo attacks both sexes and all ages, but mostly the young. 
I. sparsa affects elderly people perhaps most frequently ; in a person predis- 
posed, any irritant will evoke the disease — e. g.y local irritation, uncleanli- 
ness, solar heat, teething. ^It is most common among the lower orders; in 
those ill-clad, ill-fed, ill-housed ; in scrofulous and lymphatic, pale, and pasty 
subjects. 

JProgiposis is always favorable. 

Diagnosis, — Impetigo is known by the psydracious pustules, the yellow 
secretion drying into honey-like and subsequent thickish, dirty, yellow 
ciiists. Eczema impetiginodes is a mixed form of disease, in which the on- 
set is that of eczema by vesiculation, the discharge in the progress of the 
disease becoming like that of impetigo. 

J^ctJtj/ma is known from impetigo by its phlyzacious pustules ; the hard, 
inflamed, indurated base ; the thick dirty discharge ; the adherent crusts, 
and the history of the case. In sycosis there is swelling of the subcutane- 
ous cellular tissue, indurated pustules, little secretion, change in the haii-s, 
the presence of a parasite, and, in later stages, ^' tubercles,'' and the disease 
is seated at the hair follicles. 

TrecUment. — This consists mainly in the administration of remedies cal- 
culated to counteract the evil influence of the lymphatic or strumous tem- 
perament present — as cod-liver oil, iron, quinine, milk, good animal diet, 
together with, locallj, the use of emollient and subsequently astringent 
remedies. In the early stages of disease, when there are acute genei-al febrile 
symptoms, salines, purgatives internally, and emollient cataplasms, poppy 



94 IMPETIOO CONTAGIOSA. 

decoction, warm lead lotion, zinc ointment extemallyj are useful. If there 
be any initation from teething, the gums must be lanoed. 

Before commencing the exhibition of tonics, the bowebs should be care- 
fully attended to. Saline ai)erient8 in those of pretty good age ai*e called 
for, especially in servants who have had very little exercise, and who ** stuff'' 
themselves with unwholesome articles of diet. Having, however, rectified 
any error of this kind, we at once employ tonics, generally cod*liver oil and 
steel. Where there is any amenon*hoea, a course of iron is called for. 

With regard to local treatment. At the outset, and in direct proportion 
to the degree of irritation present, our remedies must be of an emollient 
nature. Poulticing, fomenting with decoction of poppy-heads, to remove 
the crusts and allay inflammation, is the first step. Weak lead or borax 
lotion may then be used, and subsequently an ointment made of a drachm 
of the nitrate of mercury, or three grains of the ammonio-chloride to an 
ounce of lard. If the scalp is affected, the hair must be cut from around 
the disease. Pediculi are to be destroyed by the white precipitate ointment, 
chloroform vapor, the pyrethrum roseum or stavesacre ointment. I prefer 
the former of these. In many cases alkaline lotions are of use— «x. gr., 
carbonate of soda (sixty grains to six ounces of water). 

In imi)etigo scabida other steps mubt be taken ; the general health must 
be regarded from a gouty, a rheumatic, or a latent strumous point of view, 
and treated accordingly — ^the kidneys es];>ecially made to act well. The diet 
should be good and unstimulating. Then locally, the scabs are to be re- 
moved by rei)eated soaking in glyceiine lotion, and by poulticing, and the 
denuded surfaces may be treated with lead lotion, tannin and glycerine at 
first, and then the white precipitate ointment, or one composed of pyrolig- 
neous oil of juniper two di*achms, and sulphur ten or twelve grains, to an 
ounce and a half of lard. Finally, painting with nitrate of silver solution 
will heal tlie surface, and if the limb is affected, and the skin is much swol- 
len, careful banding must be resorted to. In impetigo of the beard hot 
fomentation, the exclusion of air as much as possible, a course of iron with 
acids and sulphate of magnesia, and locally alkaline washes, then glyceral 
tannin, sulphate of zinc lotion, and the nitric oxide of mercury ointment^ 
generally suffice. 

IMPETIGO CONTAGIOSA, OR CONTAGIOUS IMPETIGO. 

I am anxious again to direct attention to the clinical features of a com- 
mon form of cutaneous disease, seen especially in dispensary and hos- 
pital practice, and universally classed by practitioners with eczema impeti- 
ginodes or impetigo simplex, but which is, as regards nature and ti*eatment, 
a wholly distinct affection. Its cure is usually certain and easy by local . 
means. It is classed under the term ix>rrigo, as used by some writers, and 
is one of the many varieties of eioiption which together constitute the com- 
posite ** scald-head." I have hitherto called the disease contagious impeti- 
go ; for it is essentially inoculable (contagious). It is often ^an-epidemic ; 



IMPETIGO CONTAGIOSA. 95 

it differs in severity and in features at different times, tends to run a defi- 
nite course, exhibits a uniformity of character as regai*ds the eruptive condi- 
tion, and is vesico-pustular in type. Mr. Wilson has recently stated that 
the disease is a distinct and common one. I had the pleasure of showing 
Dr. McCall Anderson some cases a few weeks since, and he acquiesced in 
the special natui-e of the disease. Dr. Clifford Allbutt has informed me 
that he is now satisfied as to the existence of the affection as I have de- 
scribed it. 

Clinical history. — The disease is seen amongst children of the lower 
orders especially, probably in great measure because the opportunities for 
contagion are more numerous, but occurs also in those who have all the ad- 
vantages of social ])osition and good hygiene. It is ushered in occasionally 
by smart, generally by slight, fever ; or the child looks ill, pale, languid, 
and is said to have been *^ in a burning heat,^' or to have had " cold chills.^' 

There is clearly an affection of the system at large before the occurence 
of any eruption, which in the majority of cases appears first of all on the 
face, or top or back of the head, in the form of " little watery heads " (ve- 
■icles), that enlarge into flat bullae. Sometimes the hands are attacked at 
the outset, and look as if burnt here and there ; phlyctense may also arise 
out of and around the remnants of vaccinia, or about cuts or bi-uises. The 
disease then extends to other parts, the back of the neck, buttocks, feet, 
etc. The vesicles are always isolated. In five or six days the bulla may 
reach the size of a sixpence or shilling, unless ruptured, and then it is flat 
and depressed in the centre, the contents becoming turbid. The secretion 
consists of lymph-like fluid, granular cells, and subsequently pus-cells. 

Scabs commence to form a few days after the appearance of the disease. 
They are characteristic of the disease, varying in size from that of a split 
pea to a shilling ; they are flat, sti*aw-colored, dry, and granular-looking, 
and appear as if '^ stuck on ^' to the part ; they present, as a rule, no in- 
flammatory areola around their circumferences, though this is the case in 
severer instances of the disease. If removed, little sores are observed be- 
neath, more or less filled in by gummy-like secretion, or a little pellet of 
aplastic lymph. The disease may be spread from spot to spot by direct in- 
oculation with this secretion in the act of scratching. The crop of vesicles 
is to some extent successive, though the majoiity of the places *^ come out " 
in the first week or so. In some instances the disease resembles vaccinia 
very closely. There is always a uniformity about it ; it always commences 
by vesicles ; there are no papules present at the height of the disease. On 
the face the spots may be confluent, and then the disease resembles eczema 
impetiginodes ; but the patches are made up of the elements described 
above. On the head the disease consists of circular, mostly isolated, flat- 
scabbed spots about the top and back of the head, the hair being matted by 
the crusts. There are usually no pediculi and no offensive smell. 

The mucous membranes of the eye and the nose are often implicated ; then 
inflammation is produced by the development of little ulcers, that take 



m niPEnOO 00STA0I08A. 

their origin in the (tevclopinent apparently of vesico-pustuleft, ideoticAt with 
thoee seen on the surface of tlie akin. Tlie eye may look as tliough affocWd 
hy alight ]turu1ent ophthalmia, but soon recovei-s itj^elf. All tJie children 
in a house may he attacked at one time, oi' consecutively, by the diae^ae, 
and in such a way aa to impress upon friends and attendants the idea of its 
being contagious, and luider these circumstances it may be regarded aa 
BCabiea. It may eomplitxtUi eesenva, aeahiei, and other affections, awt vtcevend. 

Diaffnintic featurea. — Ita appoi-ently epidemic character in many OBaes; 
its att)i«king childi-eu ; the antecedent febrile condition ; the origin frOm 
isolated veaicleo, which tend to enlarge into blebs, and to become pustular, 
the bleb having a depressed centre, and it may be, a well-defined, slightly 
raised, rounded edge ; the isolntioH of the spot"), the vnl/arm character of 
the eruption, and its general and scattered condition ; its seat, and frH]aeiit 
commencement about the face or head ; the circular, flat, granular, yellow 
crusts ; its couU^ous natni-e and tnoculability ; its frequeiitly following in 
tlie wake of vaccination ; the implication of the mucous membrane of the 
eye ; the abaeuce of pain, and eapecialty troublesome itching at night. 

It may be confounded with eczema j but the history is altogether differ- 
ent, and the isolation, the small scabbed ])atch, tlie characters of the crusts, 
and the facility of cure, at once distinguish it. Impetigo sptirsa does not 
arise from a vesiculation, but is primarily pustular, mode up of aggregated 
pustules; it is :iot phlyctenoid; it is not contagious nor inoculable ; it 
does not run a definite course; it in not confined to the young; it is not so 
amenable to treatment. Pemjfhii/vi ; but here the blebs are more persistent, 
oval, and distended ; the contents are watery and acid ; it ia non-con tagioua ; 
it docs not occur especially on the face or the head ; it is less inflammatory, 
and wants the characteristic scabs. ^cMynw/.-Thisisprimarily a pustular dis- 
ease, seen also in adults; tbere ia more induration and swelling; a good 
deal of pain ; it is non-contagious ; the scabs ai« heaped up and dark. Pv*- 
tutor fcabift: Tliia is the disease with which it ia mostly confounded. 
It must be remembered that the two diseases may co-eiiiflt. Both in cAi^ 
dren attack the buttocks especially ; both may exist about the hands and 
feet ; but the distinctions are rarely very clear. In scabies there is no 
febrile con<lition ; ihe eruption is tnvlti/onn. If there be ccthymatoua 
pustules, like imjietigo contagiosa, they are covered by dark thick crusts ; 
there are plenty of characteristic vesicles, with cnniculi, and papides. If 
the iini>etigo contagiosa begins alwut the buttocks, it appears presently on 
the face or the he-ad, or both. There is not the irritation of scabitts, so bad 
at night, nor the effects of scratcbings about tlie body ; the bullous origin 
of the disease is distinct, and the peculiar scabs are thoracteristio. Tba 
hands are not speciidly affected in scabies in the child, but evm impetigo 
coutagiosB may attach the hands and feet markedly ; still them ia no mtd- 
ti/'orm eruption. Inocuktiou will settle the point in twenty-four houra if 
we cannot find on aonrus. We mivtt not be misled into the idea that scabiea 
exist because several children in tbe aame house have a certain disease, Mad 



ECTHYMA. 97 

have apparently caught it the one from the other — a rule adopted hy very 
many. Lastly, the two diseases may occur together. 

When a correct diagnosis is made, the treatment is easy. TJie natural 
cotirae of the disease is a short a/nd definite one. The disease sometimes 
occurs in badly-hygiened subjects, and, therefore, tonics may be given. 
The secretion is a most active element (per inoculation self-practised by the 
patient) in transmitting the disease to different parts of the same subject or 
to others ; and this ensures perpetuation and chronicity. And, therefore, 
we should destroy the secretion, and then alter the behavior of the 
surface that yields it. Astringents and antiseptics avail ; but the best is a 
little ammordo-chloride of mercury ointment — five grains to the ounce. 
The scabs should be removed, and the ointment applied to the secreting 
8ur&ce. The disease is supposed to be due to the contact of those attacked 
with non-specific unhealthy pus; but there are many reasons against this, 
which cannot be noticed here. It is a very definite disease, dependent 
upon a particular poison; easy to treat, but little known. 

Impetigo Rodens. — Under this term have evidently been included many 
different diseases. Hardy calls the affection scrofulide pustuleuse. It is; 
said to occur about the sides and tip of the nose, first as small pustules on a 
red base, that break out into ulceration, and are replaced by a brownish: 
scab, which covers over a dirty foul ulcer. But impetigo is a superficial 
pustulating and non-ulcerating affection; the word rodens signifies an 
'^ eating out,'^ and it is most probable that by I. rodens has been meant now 
a syphilitic, now a scrofulous ulceration. 

ECTHYMA. 

This disease is described as consisting of isolated phlyzacious pustules — 
viz., those which ai*e " large, raised on a hard base, of a vivid red color, and' 
succeeded by a thick, hard, dark-colored scab, beneath which there is ulcer- 
ation." The pustules are generally distinct, round, and isolated ; they are 
mostly general ; they may be partial, and leave cicatrices behind. The 
shoulders, buttocks, and limbs are the parts usually attacked. There are 
two chief forms — acute and chronic. Tlie local symptoms are generally in 
direct ratio to the amoimt of general disturbance. 

Acute ecthyma commences with slight febrile disturbance, and occasionally 

sore throat ; locally, a sense of heat and burning, followed by the appearance of 

reddish raised points, with hard indurated bases, and distinct vivid ai'eol» ; 

these points quickly pustulate, vary in size from that of a pea to that of a 

shilling, and are often accompanied by acute, sharp pain. In two or tliree 

days the pustules give exit to discharge, which dries- into hard, adherent, 

dirty, discolored scabs, covering over circular ulcerations : the ci-usts fedl off 

in a week or so, leaving behind dark stains. The eothymatous spots may be 

many or few ; in the former case a good deal of irritation is set up ; the 

patient may be unable to sleep from pain, and the glands and lymphatic 

vessels may become inflamed, and small abscesses form. The disease is 
7 



98 ECTHYMA. 

generally protracted by successive crops of pustules, or it may relapse into a 
chronic state. The limbs, shoulders, and trunk are the seats of the disease. 
Chronic ecthyma occurs under thi'ee forms : — 

a. E. infantile^ which is the disease as seen in ill-fed, half-starved chil- 
dren, fed by unhealthy mothers. The pustules vary in size — some are 
small, some large ; the crusts are dark ; the ulceration unhealthy, giving 
out a foetid and sanious pus. The disease affects the body generally, often 
commencing about the lower limbs ; the scalp may become the seat of the 
disease ; the child often wastes, becomes hectic, diarrhoea may set in, and 
death ensue about the fifth or sixth day. 

b. E. luridum^ seen chiefly in old people and debilitated subjects : it is 
usually extensive ; the pustules are large, slow in progress ; they have a 
dull, livid look, a dark areola, are filled with sanguinolent curdy fluid ; in 
a week or ten days they discharge their contents, which are dirty and foetid, 
and scab over or ulcerate. 

c. JEI. cachecticum is pretty much the same disease ; it is seen mostly on 
the lower extremities ; there is not so much of the livid aspect ; it is rather 
more active ; the subcutaneous cellular tissue is involved : the contents of 
the quasi-pustules are not so sanguinolent as in E. luridum, and there is 
not so much ulceration ; there Ls often a good deal of fever. 

In the last two varieties the eruption is really something between a bulla 
and a pustule. Ecthyma, it must be remembered, may result from any 
long-continued irritation in badly- nouiished subjects. It is a frequent com- 
plication of scabies and prurigo. 

The three chronic varieties are but stages of one and the same disease ; 
so-called IC. gangrcenosum is rvpia escharotica, 

JPaifiology. — Ecthyma is clearly pyogenic in character ; the seat of dis- 
ease appears to be the uppermost layer of the derma, not unlikely about 
the glands of the skin ; the depth of surface involved is less than in furun- 
culus, and there is no " core ; " otherwise ecthyma would be well classed 
with boils, and described as differing thei*efrom in the fact of its more 
diflnse suppuration, and the aplastic character of its pus, explicable by the 
cachectic state of the patient. The tendency to ulceration and sloughing, 
the lividity of the inflammatory areola, the disturbance of the gcuei-al sys- 
tem, all point to a cachectic condition, which is readily explained by a 
reference to the so-called Cav^M of the disease. These are always such as 
lead to debility and an impoverished state of blood. They are in infants, 
bad nursing, suckling by mothers much out of health, scabies, bad clothing, 
damp dwellings ; in adults and others, over-work, fatigue, convalescence 
from acute diseases, bad food, privations, various occupations that induce 
irritation of the skin — ex., bricklayers, excesses of all kinds, debauchery, 
uncleanliness, night-watching, overcrowding in public institutions, work- 
houses, jails, hospitals, and such-like. 

JPrognoM is to be made according to the general condition of the patient. 
The ecthyma, per m, is of little guide, save when it is of tiie Ivrid variety, 
in old people ; then it is grave. 



iagjtimt. — The distiunt, largo, isolated pustules, with an inflamed areola, 
liard base, <listribut<>d over the body, are very distinctive of the disease. 
It may be confounded with Impetigo uparaa, but in this diseaee there aj;e 
rather sero-piiHtulee than pustules ; the dischirge is viscid, yellowish, there 
are no dark scabs, no indurated, inflamed, and painful baaes. Fii^runeidut 
is deeper, it nina a slower course, and contains a central " slough " or 
" core," as il is calloil. It is more circumscribed, and there Is little scab- 
bing. In Seabif« ecthymatous spots are constantly seen, especially about 
tlie hands and feet, and in conjunction with other signs of scabies, being 
secondary in point of time tJiei-eto. J'ruriijo is complicated by ecthyraa. 

^^Che iH)nical, dark. Iieaped-up, stratified crusts of rupia distinguish that dis- 

^^^■B from E. cachecticuui. 

^^^HVea<m«nt.^We must recollect that ecthyma is a cachectic disease ; that 

^^^bften occurs in those in whom the eliminating organs are sluggish, at the 
same time that effete material lias been largely prMiiioed in the system. 
Firstly, if secondary to scabies or prurigo, we must treat the priniary dis- 
order, then with the aid of tonics the ecthyma will soon disappear. Again, 
if it arise from the action of local irritants upon unhealthy skins, as from 
the contact of lime or sugar, we have only to remove these sources of evil, 
and use soothing remedies with astringents— alkaline lotions, or glyceral 
tannin, or biborato of soda or zinc ointments, and give internally iron, min- 
enU acids, or other suitable tonics, for tlie case to get well. But suppose 
there is no external canse of this kind, we must ti'eat the impoverished 
state of blood which gives rise to the disease. I am of strong opinion that 
vUmination first of all needs attention. In young subjects, saline aperients 
togetlier with tonics are the best remedies. After a good colocynth purge, 
the exhibition of such a mixtui'e as sulphate of magDctria, sulphate of iron, 
tincture of calumba, and cuinamon water, or if the appetite is bad, dilute 
nttro-hydrocliloric acid with sulphate of luagnesia, quinine, and infusion of 
roses, soon improves the whole tone of the system. But this end is still 
further secured if we take care that our patient eata wholesome food, that 
he gets his proi>er rest, sod the proper amount of air in his aleeping-room ; 
especially that he is cleanly, and not over-worked. All these are material 
points in tJie treatment. If the patient be young anil growing, ho must be 
well dieted, have a sulticient amount of wine<>r sound beer, and take cod- 
liver oil. Then locally, in these acute cases, emollients are alone admissi- 
ble — warm lead lotion and poppy-head fomentations. Presently we may 
Bnbiitittit« opiate and tannin ointment — extract of opium, ten to twenty 
grains, a scruple of tannin, with an ounce of simple ointment. I trust to 
the general and not the local remedies. Then there is still the chronic 
form of ecthyma to deal with. Even here 1 lay great stress on a sulKciency 
of aperients, and on the mineral acids, with bark, bitters of all kinds, 
(piinilte ; if there be ranch nervous disturbance, pain, restlessness, and the 
like, opiates judiciously exhibited are of service ; change of air will some- 

^Itoea work wonders. In the eaeherlic vaiietiea, free living, pleilty of meat, 




100 FirRtTIfQDI,AR AVfECnOlTB. ^^H 

wine, with barb fuid ammonia, must needs be given ; and locailj in olif|^^| 
ectbyma the scabs shuuld be removed, and attempts made to get cleaa ST 
healing surfaces by the application of weak Condy'a fiuid, weak csi'boUe 
acid lotion, simple Kulphur ointment, or weak nitrate of silver lotion, when 
it is neceESory to stimulate. If there be much irritation, lead and opium 
lotion, or charcoal dressingB, may be of service, A good application is an 
ointment made by rubbing together an ounce of lard, and half a drachm or 
BO of Friar's balsam. 

No two cases are exactly alike, aud the special knowledge of the phyt 
ia often needed to detect some flaw in the performance of the organic £ 
trons which mainly determines the occurrence of the disease, 
mediefi will be found in the formulary. 

FUBDSCOLAR AFPE<.TI0N9. 

I have said that furuncular affections differ from impetigo and eothn 
amongst other things, by being deeper, and by their pustules c 
their centre a dead piece of tissue which is called the " core," in fact a ii 
tnl " slough.'" This " core " is indeed the essential fe-ature of a boil. Nov 
we are told in books, and expected to say at examinations, tliat furuiiculus 
or boil, anthrax or carbuncle, and malignant pustule, ore forms of one and. 
tha same disease. But maligiioat pustule is produced by i 
poison, and should be ranked elsewhere. The general character of fa 
cular affections is in the occurrence of inHammation of a limitttd e 
affecting the tissues deeply, the central part dying and formii 
Some think this core is a true exudutiou, some a piece of " dead celluUra 
sue." Wben a boil is, so to speak, multiple, when there are several '* 
and the cellular tissue is much involved, and more or less sloughy, thsni 
have a carbuncle. But, to put it in text-book language, " the characte 
distinction between furunciilus and anthrax relate to their prominence, d 
breadth, color, number of cores, a-nd degree of pain." Fiirunoulua i 
solitary piistulation ; it is more prominent, leas deep, involves leas of thafl 
sues around, liaa a doep red areola which assumes a bluish tint aftsra wk) 
the " core " is single, and the pain is less severe. Anthrax ia less prom 
it is deeper, involves more tissue, is much darker in color, pomessea xaaay 
"cores" (dead tissue), and is accom.]>anti!d by greater pain. 

First of 

rURrKClTLUB, OB BOIL. 
The general tifmjilomt a.re a» follows in some cases: — Febrile disturb) 
rigors, loss of appetite, headache, disordered bowels. Locally, a UttlAa 
lump, the size of a sjilit pea, Di&kt^ it« appearance : it is tender, pauiful,(fl 
tense ; this soon becomes indurat«<i, the tlisease is felt to bo pret^ d 
i-ed blush surrounds the base of the swelling, aud chnuges from b 
, to purple. In from three to six days, the apex of tlie boil becoinea yd 
from llie formation of pus : the pain ia now tlirobbiug, tlie iuduratioa a 
uos at the base augments, and so does the amount of pus in tha a 



FURUNCULAB AFFECTIONS. 101 

the pustule. If left to itself, ^^ the pustule " bursts, and presently '^ the 
core '' eomes away, healthy granulations at once spring up, and repair is 
quickly completed. Sometimes the suppurative stage is scarcely reached, 
and then we have blind boils, Furuncuhis generally attacks the neck, but- 
tocks, arms, especially in young people, and there are successive crops of 
pustules, so that the disease often lasts a considerable time. The glands 
may be enlarged. The pain is severe in boils that occur in parts that are 
dense and cannot swell, as in the meatus of the ear and the pudendum, or 
those that are freely supplied with nerves, as the face. 

ANTHRAX, OR CARBUNCLE, 

Is a multiple furuncle ; it arises as a hot hard swelling, not so conical as that 
of the boil, more indurated, however, the cellular tissue around being much 
more extensively implicated ; the color is dusky, the sensation burning, dull, 
throbbing ; in size the carbuncle varies, the swelling becomes '^ brawny,'^ 
due to the meshes of the cellular tissue becoming filled with aplastic lymph« 
The next step is the formation of a qiioH-ahaceas ; the central part softens, 
feels boggy ; the skin thins over the surface, and at several points openings 
occur, through which slowly issues more or less sanious pus ; and the little 
holes are seen to be plugged up by small white cores, which presently loosen 
and come away ; the apertures are red and papillated, the edges indurated 
and everted, particularly when several openings coalesce, so as to form one 
or more large openings. Gangrene may set in ; the healing process is often 
indolent ; the parts remain undermined, brawny, dusky, shreddy, and also 
sloughy. Carbuncles are generally solitary. The patient, if the attack be 
severe, gets into a very depressed state. The posterior aspect of elderly 
people is the selective seat of carbuncle. I shall refer to the cause together 
with that of boils. 

HORDEOLUM, OR STY, 

Is a small boil seated at the edge of the eyelids, and involving a Meibomian 
gland. It is not an active kind of boil, but progresses sluggishly, the pus- 
tular centre being small ; it is painful, and some time lapses before all traces 
of its existence go. There may be one, two, or more, on one or both 
eyelids. 

Pathology and Cause of Fwruncvlar Affections, — ^Now, under what con- 
ditions, first of all, do boils occur — (1) during seasonal changes in spring 
and summer; (2) from eating diseased meat (frozen) ; (3) when any special 
alteration is made in the ordinary habits and economy of the body, as in the 
training of prize-fighters ; (4) from the influence of cadaveric poisons ; (5) 
from sudden change of diet; (6) after fatigue of long duration; (7) dur- 
ing convalescence from debilitating diseases ; (8) as a consequence of the 
action of septic poisons, as in fevers, etc. ; (9) in albuminuria ; (10) in the 
diabetic habit ; (11) during adolescence, and in the first stage of manhood. 
In meet of these cases there are '* debility " and an overloaded state of sys- 



103 ?dhi;kodl&.b ArvBcrnnra. 

tcm — ex., the circulation of urea, of sugar, of septic poison, or of rlT«>te 
matter which ia plentiful during couvaleBceiice. But with this st«t« of 
things — i.e., evident general disorder of the syatem — the local iuilaram&tioa 
is active, and the auppuration is " healthy," the pua laudable, the procesii of 
repair peculiarly vigorous and complete in its character. Now, it is this 
which gives the lie, as it were, to the doctrine that a boil is due to the 
occurrence of a epontaneous gangrene or death. It aupposes that there are 
two actions going on side by aide of diametiically opposite ckaraclera — ■ 
gangrenous and a vigorously reparative one. If the primary death result- 
ing in "the core" were due to h tendency to gangrene in the systnm, 
why should there be present in tlie same subject and in the same part a 
thoroughly satisfactory process of repair. What, indeed, ia there iu the 
clinical history of boils, or the condition of patients atfccte«l by them, to 
account for the apontaueoiia death of a piece of cellular tissue V If " the 
core " be regarded cui an exudation, we have no analogy to support such a 
proposition. It is clear that the only satisfactory explanation is that which 
recognizes that some disorder in the circulation of the part first takes place, 
that the tissues fail to be pi-cperly nourished, to perform their fuuctioua, 
and then die (slough), and that an attempt in made by suppuration to get 
rid of the moribund or useless tissue. M. Denucc, of Bordeaux, belieTM 
that the anatomical scat of the disease in furuncle is the sebaceous gluid 
(as is the case in sty) ; this gland, in the i)ei'forD)ance of its emunctory «ot, 
is disordered by the cflete matter with which the blood is chai'ged ; it is 
then congested and inflamed, then it suppurates, dies with the cuutiguona 
cellular tissue furming " the core," and healthy reparative action is at oiioe 
set up after the dead tissue comes away, " The core " is a dead sebaceous 
glnnd, and wore or less of its contiguous cellular tisstie. It is easy to see 
how it is that friction and irritants of all kuids determine the seat and 
occurrence of boils in those who are pi'edisjiosed to them, It is said iu the 
case of a blind boil wo have uii iuHameci sebaceous gland, which hap]>ena to 
recover itself before the stage of suppuration is reached or needed. Boils 
occur in parts whet's the glands are lai'ge, where the skin is tough, and liable 
to be injured — ex., the back of the neck, shoulders, and the outer side of 
the limbs. The boil varies iu character and degree according to tlie depth 
of the cellular tissue around the gland involved, and the state of the blood ; 
boils are lai^ and severe in debility after c-onvalesccnce, in diabetes, albu- 
niinaria, and the like ; sinsll and painful in young and plethoric faubject*. 
If boils are the result of an inflammatory state of the skin glands, thur 
occurrence in fuU-blooiled and apparently healthy persons is exjiUined bj 
the overchargeil state of the blood with the waste products of the bodj. 
Ill cootraating boils with simple acne, we notice that the latter is merely « 
choking up of the scbaceoiis duct by fatty secretion, with more or less 
secondary inflammatioD ; there Is not necessarily suppuration. In boils the 
whole gland itself is involved, not merely the excretory duct ; the alte 
of the blood current is primary — the gland is disordered and ii 



FTIRUNCULAR AFFECniONS. 103 

consequence. In acne rosacea we have a closer approach to a boil ; tbere is 
not suppurative but plastic inflammation of the gland and the tissue outside. 
Let acne rosacea suppurate freely, and though the cause be different the 
result is mainly the same. The microscopic structure of " the core," it is 
said, bears out the opinion here expressed, to which I have long inclined. 
In carbimcles we have a similar action to that in boils, but a much severer 
degree of disease. Here a gi-oup of sebaceous glands is involved, and in 
consequence of the more cachectic state of the nutrition the i-eparative 
attempt is less perfect, the inflammation is of a lower type, and the cellular 
tissue to a much greater extent sloughs and dies. The nutrition is not only 
unequal to prevent the local disorder, but also incapable of putting repair 
in proper operation ; and what is the blood state in carbuncle ? — a tendency 
to a diabetic condition. This has been exemplified of late by many observ- 
ers — Prout, Goo] den, Landouzy, Wagner, De Calvi, Fonseca, Menestrel, 
Kiichenmeister, and others. Anthrax is very common in Pemambuco, and 
Fonseca finds it connected with diabetes, or a diabetic tendency. Sugar occurs 
in the pus of the carbuncle, and it is a curious fact — so it is stated — that 
when anthrax develops, the sugar is diminished or disappears from the 
urine. M. Vemeuil not long since corroborated Wagner's observation 
relative to the occurrence of phlegmonous and gangrenous inflammation in 
diabetics, before the Fi*ench Academy, in certain cases of gangrene of the 
lower limb occurring in ' connection with saccharine urine. Lastly, I said 
that ecthyma and furunculus, save in the absence of the ^' core,'' bore some 
resemblance. I cannot but think that some change in the blood current 
leads to superficial suppuration about the upper part or the ducts of the 
sebaceous glands in the topmost layer of the derma, in ecthyma, in which 
disease a pyogenic habit of body is present ; at any rate, boils and ecthyma- 
tous pustules often occur together. 

Diagnosis of J^oils and Carbuncles, — No error can possibly be made in 
respect of these two diseases ; in the former, the hard, deeply seated indura- 
tion, the pain, the central suppuration, and the '* core," are distinctive. The 
manifold openings, the boggy feel, the sloughing, the grumous discharge, 
and the implication of the cellular tissue in carbuncle, are very pec\iliar. 
Furunculi are sometimes epidemic. 

IVeatment, — If the view I have given of the nature of boils be correct, 
then we may at once lay down a definite plan upon which to base our treat- 
ment. Boils are accidents common to many conditions, but produced in all 
these upon a similar plan — viz., a disordered blood condition, with nutritive 
debility and deficient elimination in subjects whose tone is lowered. Firsts 
of boils. There is always deficient elimination ; it may be in a yoimg and 
naturally vigorous youth who is rapidly growing, and is perhaps hard 
worked, and who does not get quite the right food he needs, — it is plentiful,, 
but scarcely wholesome. If the disease assumes what may be fairly called 
a sthenic form, here saline aperients and a modified diet suffice ; but where 
there is marked want of tone, in such a case sulphate of magnesia, infusion 



104 FtJBUNOULAR AFFECTIONB. 

of roses, and quinine at first, and then cod-liver oil, would be the proper 
remedies internally. Again, in those who are breathing a vitiated atmos- 
phere — in the dissecting-room, for example — change of air, quinine, aperients, 
and rest, soon improve the general condition ; or bark and chlorate of potash, 
with the mineral acids, are equally good medicines. In the case of individ- 
uals of mature age but good average nutrition, the emunctory functions may 
be disordered ; here we must again eliminate and tone. If the urine be 
loaded, and the bowels irregular, the combination of acetate or bicarbonate 
of potash with ammonia, followed by calumba and an alkali, are advisable. If 
there be a gouty diathesis even colchicum or iodide of potassium are called 
for, with toiiics. In the case of boils occurr^g during convalescence from 
febrile diseases, there is still the removal of waste products to attend to, 
and the necessity for tonics at the same time. These remarks mainly refer 
to young persons ; but boils trouble middle-aged and elderly folk. In some 
instances we have to deal with careworn and anxious men and women, who 
have a pretty hard struggle to maintain their position, and a good many 
mouths to fill at home, and who are yet originally healthy and sanguine 
subjects. The diet of these persons has been deficient ; it requires to be not 
only more ample, but more varied, if possible. Here again aperient tonics seem 
to me to be indicated, and I believe that opiates (the watery extract) freely 
given, if there be much nervous excitability, will lull the patient, both as 
regards his pain and his depression. Then it is of prime moment that we 
are sure that our patient^s gall-bladder is properly emptied. In some in- 
stances of over- worked middle-aged persons, the sallow complexion, the al* 
most actual icterus, the loaded urine, flatulent dyspepsia, and want of tone, 
point mainly to a congested and inactive liver as the source of mischief. 
Such a case demands podophyllin in repeated doses, the nitro-hydrochloric 
acid internally with nux vomica, and the careful regulation of the diet ; the 
avoidance of saccharine matter, pastry, and malt liquors. In young women 
who are naturally of good constitution, and who get somewhat ansBmiated, 
or have their menstrual functions disordered, boils are often seen about the 
armpits. In such cases aloetics and quinine with iron, moderate exercise in 
the open air, und plain food, are called for. In all cases fresh 
air, abstinence from work, if at all needed, and frequent ablution, 
should be prominent it^ems in the treatment. With regard to local treat- 
ment, in the vast majority of cases boils always run on to suppuration, and 
the object to be attained is the removal as quickly as possible of the " core,^^ 
or dead tissue, whilst we improve the general blood condition. In the 
slighter forms, which we know by experience will probably " subside,'* 
emollients may be applied, lead lotion, warm applications, poppy-head fomen- 
tations, or pressure by means of 8oa[>-plaster, by which means boils may be 
helped to abort ; we may attempt by aperients and diuretics, if need be 
with tonics, to prevent their formation. In the more decided forms we 
encourage the suppuration, help the evulsion of the dead tissue, and favor 
the healing of the idcer subsequently left. We must also allay pain. Now 




poulticing, the prevention of local irritation by projier protpction, TtMing 
nffectwi purt if this is possible, ai-e the meaiiH generally employed, aa every- 
'fe6dy knows ; but though practitioners linow thin, they do not appi^eciate the 
ilingent fnct< that, inasmuch as locaj irritation of all kinds determines the 
|i0eean'ence of boils, local reniedioa, such es poulticing and the like, nhould be 
r'oonGned as mnch as possible to the exact seat of local inflammation. Kotli- 
lilttg is more common than the spiingiug up of fresh around old boils from 
tiie neglect of this precaution. Now, when suppuration has set in, then we 
may hasten the preparation and exit of " the core " by tlie application 
RTOund its indicated locality of potassa fusa or acid nitrate of mtrcury. We 
may, to sum up, attempt to moderate and limit the mippurative action at the 
we must, when pus has shown a tendency to form rapidly, at 
encourage it. When the " core " lias come away, any simple astringent 
dreaaing does — nitrie ncid lotion, with or without opium — the disease is 
over, and Nature quickly repairs the damage done. Then general and local 
treatments are dii-ccted to lone up the system and to prevent a repetition of 
mischief. In all cases of boils there are conditions which show that the 
health of the patient is natui-ally vigorous, that it is somewhat perhaps below 
par at the time of the occurrence of boi Is, but especially that effete products 
nre in excess ui the system. DenucS is of opinion that the cutaneous glands 
^le diaordered, tJiat the gland function becoming peiTerted, the glands in- 
»uppurttt«, and tiually slough. The treatment, therefoi'e, consista in 
linating, toning up, and helping on the suppuration in the skin and the 
irge of useles!) portions of tissue. I believe this is the best and most 
Fill account I can give of the matter. Then with regard to the treat- 
it of carbuncles, the same line of pt-ocedure holds good, only the const!- 
ioDal condition is one of more serious importance; it is one produced by 
an influence as a diabetic tendency. The local mischief is therefore 
and more extensive, the suppuration is less healthy, more tissue dies. 
QUght H«veral glands perish, forming so many " cores," but their sur- 
iding cellular tissue is specially involved in the death or slough ; the 
itive arcumscribiiig action ia not so manifest, the healing is not so rapid 
or jierffct, and serious results are more common. Uric acid is allowed to 
be more abundant in the blood. The indications are clear — the combating 
of gouty tendencies, and the stimulation of the liver and kidneys at first, 
restriction of the diet to plain aniuial food, and lai^e doses of quinine 
opium — the latter if there be any decided diabetic tendency or mu<^ 
'WIS prostration — the whole tempered with the aid of more or less 
lulation, good nursing, and the freest support, as the case may need. 
Now we know that if tlie patient is tolerably strong and has no organic 
the carbuncle itself will slough out, and reparative action qnickly 
The case gives us no anxiety, but we may materially aid the core 
isoderale inllammatory action, by aperients, by diuretics, by opiates, or 
tonici. In one case the patieut'e- strength malj fail at an early period, 
bece we give what would be inadmissible in another — port wine, plenty 



106 PUBTULA MALIGNA. 

of strong beef-tea, and full doses of bark and ammonia ; but yet we must 
not forget the diabetic tendency, or the importance of liver and kidney ac- 
tion. Then with regard to local measures. It is clear that the sooner the 
carbuncle is ^^ ripe '' and the dead tissue away the better ; thereby the sooner 
the pain and its effects on the body generally are lessened, and the sooner 
Nature can commence repair. To this end we need to keep out the blood 
from the tumor, and to destroy artificially the part that will die; taking 
measures, by internal medicines, to bring the blood back as quickly as pos- 
sible to a condition of healthy activity. And so, locally, we employ pressure 
by strips of soap-plaster ; if this does not seem to succeed, we incise to relieve 
tension and pain. The incision may be subcutaneous or not, crucial or single. 

Surgeons are mostly in favor nowadays of pressure, and afterwards 
caustic applications, with poultices to hasten the softening up of the car- 
buncidar swelling ; pain being met by opium once or twice a day. When 
the process of repair is approached, stimulating applications are needed ; the 
best perhaps is some Friar^s balsam, a drachm, say, rubbed up with an ounce 
of lard, or a carbolic acid ointment. M. So\ile, of Bordeaux, has suggested 
that Yienmi paste be applied early, and an incision be made the next day : 
this prevents the presence of a wound that can absorb from without into 
the veins, whilst the dead tissues are the more readily removed ; after the 
incision, the wound is to be dressed with tincture of iodine more or less di- 
luted. 

In both boil and carbuncle a certain part has to die and come away. The 
sooner this occurs the better, and therefore I think that caustics are the best 
remedies, incisions being employed to relieve such tension as cannot be pre- 
vented by pressure. 

PUSTULA MALIGNA, OR MALIGNANT PUSTULE. 

Within the last few years very definite facts have been obtained in regard 
to malignant pustule. The disease is characterized by the occurrence of a 
boil-like infiammation, accompanied by gangrenous changes, and produced 
by the contact of a certain animal poison derived from beasts affected with 
the disease called charbon, or Sang-de-rate, which has prevailed from time 
immemorial on the Continent. 

General Description. — The disease varies in severity according to the 
amount of tissue involved, the degree of gangrene, and the occurrence of 
secondary pyasmic results. It attacks the exposed parts or those which 
come in contact with the hides or secretions of diseased animals ; therefore 
the face, and neck, and hands, are the chief seats of the disease. It com- 
mences as a vesication on these parts, accompanied by induration, an in- 
flanmiatory blush of dusky hue, and filled with sero-sanguinolent fluid. At 
first there are itching, heat, and burning ; the central part now blackens and 
forms an eschar : in severe cases a large surface becomes rapidly gangre- 
nous. When this stage is reached, constitutional symptoms of a typhoid 
nature develop, and these correspond in severity to the local changes. They 



PUBTULA UALIQHA. 



follow the local Bym|)toniH, and are produced by absoqition of \io 

the gangrenous part, if death oc 

from the fourth to the eighth day. 

the bubsequeut progress of the oasi 

■■ at first a local disease. 
K'bat it is not certain what inSi 
nAe disease, 
Tlie cai>{ 



I TO 



from pyromic conditions, induced 
But the gangrene may be arrested, then 
is that of anthrax. Malignant pustule 
bacteria have been found in the blood, 
f any, these postiess in the causation of 
whether they are accideiitiwl and secondaiy to the blood changes, 
3f malignant pustule is, as stated, the contact of an animal 
Tirus, derived from animals affected with " charbon." Dr. Kichaud, quoted 
by M. Kaimbert (of Ohateauduu),hiis observed the disease lar^ly since 1830, 
tuid he now asserts that it occurs in those who touch the dead carcusseB of 
"charbon" animals, are in constant contact with beasts, or are stuug by 
flies that have feasted on the former. The disease is very common in the 
plains about the Alps from May to October, when the sheep in their pere- 
grinations die plentifully on the road. The disease may alfio be got by direct 
inoculation — as in butchers, herdsmen, drovers— from contact with hides 
or taiut«d hair of diseased beasts, and, it is said, by eating the flesh of the latter. 
In a recent number of the " American Journal of Medical Scienees," ia 
!^ paper by Dr. A. H. Smith, on Maligsaut Pustule, as it appeared tn tlie 
"ttlcuuty of Lns Cruces, New Meicico, in |fi65. Dining the suiumer of that 
jrear an epidemic resembling duirhon, or the malignant pustule of surgical 
writers, occurred. It commenced as a papule of a livid or purple color — 
lience the Spanish designation " grano negro ; " and at the earliest stage the 
tissues round about could be felt to be indurated to a considerable extent 
xnd depth, and distinctly creaked on being incised ; the section had the ap- 
pearance of denae fibrous texture, containing in the meshes dark pigment. 
The boundary was abrupt and well defined ; little blood flowed from it, and 
the sensation of the part was leas than that of the skin around. In from 
■even hours to two days the papule became like the vaccine pustule, only 
livid or black, and erysipelatous reduess extended around it, spreading often' 
times with great rapidity. The pustule and the swelling around steadily in- 
the rule. In some cases the former was stationary, the latter very 
_Aelive ; the cuticle was then raised by effusion and blebbed, and sloughing 
the pain was burning, but only in exceptional cases severe. The 
ititutionai symptoms seemed to bear an exact ratio to the extent of the 
nuBchief; the bi-eath was oflensive; tongue moist, coated; pulse 
strong, becoming small and frequent ; the akin rela.xed, perspir- 
% *hUe ; no delirium. The only one whom Dr. B. saw die was 
Cireat difference existed in the extent of the dLsease: in somo 
only a small spot was present, the aize of a split pea, made up of a tittle 
rvdness, and in a day or two the patient was well. In favoiuble cases the 
disk of dead tissue in the centre sloughed, leaving a healthy granulating 
surface behind. 

Cavts, — Dr. Smith says : " A careful inquiry enabled me to trace it to in- 
iQ from diseased auiraals,'' A distemper prevailed at the time to a 




DELHI SOIL, 

slight extent amongBt oattle, and wbs described by tbe Moxic&n mK-h«ra« 
to Dr. Smith. "The fact that in every instance the pustule ocotirrt>d in a 
piirt of the body not protect«d by clothing goes far to confirm t!ie view of 
the disease, that it is not in any degree the local nianifeatation of n onnxti- 
latiunal infection, but always the result of direct i.opal fNOorLATrox." He 
gives the following instance : — " Two men were engaged in nkinning ftD anj- 
mul which had died of the distemper. One of them had a piniptf on tlw 
face which he had Gci-atch>!d with his naila tintil it bled. The nth«r bad 
received a scratch in the face from a thorn in passing Ihrongh the ohapnnJ. 
The day was extremely warm, wid tlie men frequently wijwd the perspink- 
tion from their faces with their hamls, covered as they were with the fluid 
from the animal. In a few hours pustules were developed u])on the abr&ded 
surfuces in ])oth individuals. The disease proved fatal in one (which I did 
not nee), and the other recovered with a, considerable loss of tissue from tlie 
ohoek." .Dr. Smith says it is impoBsible to say if simply eating the diseaaed 
me»t sufficed to pve the disea.se, although many peo|)le declared they had 
not touched the meat One case afipeared aft«r handling diy bides. 

In one case a woman was attficke<l. She had eat«n, with the rrst of the 
family, of a goat tliat got the distemper, but which was killed " for fear it 
should die." Bnveral ate the flesh, but this woman alone was attacked, and 
she had prepnrtd the goat for iJie table. 

The Treatmmt consists essentially in fully destroying at the curlient pond- 
Ue moment the eschar or Tesicating part by citustic (potassa fusa), subav- 
qnently incising, applying charcoal poultices, witli chlorinated soda wnshM, 
and giving internally a cathartic ; foUowcd by free doses of tincture of stoel, 
carbonate of ammonia, and brandy, with generous diet. 

DELUI BOIL, Aleppo EVIL, AJfD BISKRA BOUTON. 

In tliis plnce some notice must be taken of these throe diseases endemic in 
India, at Aleppo, and in Algeria, respectively, whose paihobgical [lositien 
is at present uncertain. They aro believed to be allied, in many {uiKiculan, 
to anthras- These affections all hejir a close resemblance, and it is generally 
tiiought that they are the same in nature. I must content myself with tlM 
descripti.ms of those who have written upon the subject, as 1 have Utile per. 
sonal experience of these diseases. Compared with anthrax they are very 
chronic ; they are at first p^ular, then suppurate, and finally ulcerate. 

Ddhi Boil, called Arongzebe, after the monarch of that name, who snf- 
fered from it, is seen at Delhi, in Scindo, Moultan, Agra, Lahore, Muttra, 
and Aden. In 1857, at the firrt-named place, 400 to 700 per 1,000 of tbe 
troops suffered from it during their first year's residence there. - It attacks 
new comers to the cities in whidi it prevails. It is not dangerous, but in- 
tractable. The disease begins by itching; theniho patch looks reddish and 
warty in the centre, where it then HcatcB, so as to resemble a patch of lepra 
vulgarb. According to some, a small pustule next appears in the middlo; 
others say a thin idior is diaeharged ; at aU evonta, the next stage is the for. 



BIEKRA BOinOK. 



roatiou of a, brownish criist, whicli becomes elevated in the centre, whilst 



e is irritated the crust rapidly 
with flabby, iiTegular, fungoid 

Fig. 1. 




ulceration goes oo benealii, uud if the di 
uicreases. The ulcerated surface is m 
gruiula lions, that bleed freely. The 
■ora discharges a thin, darklHh -colored 
fluid, the nicer me&owhile enlarging at 
the circnmfei'ence. The reparative pro- 
cess cotnutenccs at the oeuti-e ttfter two 
or thrriu months, and more or leas disfig- 
UT«mf^t fmally rtisults. The niostcom- 
luouscutts of the disease ore the backs of 
thoelbows,forearniB, back of hands and i 
fingers, ankles, legs, face, thighs, am 
aeta the scalp. The general health i 
good, it in said. As to the cause, the na- 
Uv«s tliink that the disease in due to 
drinking water impregnated with organ- 
ic and aalbie impurities; it certainly 
affucffi those who live well and in good 
situatiuns. It ia more frwjuent after 
ruins, it is said. It rarely attacks unexposed parts; it is inoculable ; some think 
it malariaL Mr. Godwin, AMistuut-Hurgeon, Koyal Artillery, has seen 
much of the tliaease, and his experience will be found in the Lancet for the 
preeenl year. Dr. Fra^ir has also writteu on the disease in the A miy Medi- 
cal -Eeporls, 1860. I am enabled to give the two following sketches of 
the disesse from photographs of Deputy- Insjiector-Ueneral Dr. Mun«y, 
^glf the Indian Service, which were given in the Lancet a little while 

■£ukra botilt/n, or BUkra Btitlon. — The following account of what appeara 
to be thfl same disease as Delhi boil, is given by Deputy-Inspector Dr. 'Pa.ja- 
tnr, in the Army Meilical Reports for ISliT, at p. 438, and it will be noticed 
Uutt he refers to its similarity to an anthrax. " We find, in the sonthem 
Fi^. 2. part of the province of Cons tan tine, about IGO mites 

south of the sea'Coaat, at a military station with & 
considerable civil population of European colonists 
as weU as natives, an endemic disease, so common 
that it is called the * Biskra Button,' front the dr- 
cumstauce of its prevalence at and arouud Biskm, 
the first station in the desert. It is, however, not 
peculiar to this jiart of Algeria, for it is also found 
at Tougort, Ouargia, and TIcucen, and is probably 
to be met with iii all parts of the desert. It is also 
seen in paits of tLe neighboring kingdom of Morocco. 
This singular disease attacks its victims during the 
of September, October, and November, ut the end of the great 




tio 



I ALEPPO KVIL. 



heatE of summer. Conaequeotly, I had not an opportunity of seeing it in hs 
first atitge ; liut, from the debciiptioa giveo of it, it apgiears to commenoe 
with &a itching seiisatioii, long before any appearance is appreciuhle on th« 
ekin. Aft#r a time, a sniall tubercle is perceived about the fii;!e of & very 
email pea, located, very superficiallv, in the layers of the Hkin and Nut>cuta> 
neons tissue; remaining xtationary for some days, or even weeks, and cana- 
ing little inconvenience; at length it enlarges, the epidermis sca1<« off; and 
shortly, a Hiuall ulcer appears, which discharges asero-purulentfluid. Sem 
bv myself during the month of February, in its chronic stage, it present* 
precisely what I may describe an a small superficial anthrax. Differing is 
diameter from one to two or three inches, tliese patches present the apjiear- 
ance I have alluded to ; and when pressed, a thick purulent secretion oomb 
out through several openings. There were a few cases in the military bos' 
pital at Biakru at the period of my vL^it ; and with the exception of being in- 
convenient, disagreeable, and unxightly, did not appear to give any particu- 
lar pain, or cause any conetitutionaJ derangement. Tliia eruption appeara, 
most frequently, on the legs, fore-arms, dorsum of feet or backs of hands; 
on the nose, cheeks, and ears; varying from one or two spot^ to a dozen, or 
even more. The affection lasts from four to eight months as a general rule ; 
oftentimes, for a year, a year and a half, aud occasionally for a longer period. 
Whatever the period may be, the Appearance, when cuned, or cicatrizing of 
itself, as it does if left without treatment, is that of the cicatrix after a bum. 
The diseHso attacks natives, Europeans, all sexes and ail ages : and, oot»- 
sionally, relapses are met with (t. e., one attack not rendering the person tnt 
from a second invasion). Of the cause of this affection little is known. 
Bad water, heat, dirt, etc., have all Iwen named; however, these are Tery 
prevalent in other regions where nothing like this singular disease is seen. 
It has been met with in the horse in some of those regions whore the human 
race is liable to its attacks ; but not, I believe, in tlie dog. It is said not to 
be contagious. The cause of the affection not having been settled, its treat- 
ment is of course not very defined, 'lliorough change of air possibly ahort> 
BUS the time rei^uired for its cure, and is probably the best remedy. This 
dist«ae partakes of most of the characters of the Aleppo button," The 
most successful treatment is to blister the ulcers in the early stage, and ap- 
ply imtiiie subsequently. 

J he Alrjijm evil, or button, is no doubt the same thing as the lost-described 
disease. It is endemic about the Tigris and Euphrates, at Alepi>o, Bagdad, 
and BuBSorah ; it is niet with at all e^es, and attacks both natives and stmn- 
gers, the latt«^r alter a short residejice. It is like the Delhi boil, contined to 
the cities, and occurs onoi! in a lifetime. It begins as a papule, which pits' 
tulates in two or three mouths, and scbI)S over whilst ulcemtion goeA on 
beneath the crust to the extent of from a quarter to two or three inches, 
having all the characl^ra of that in Delhi boil. After a year or so the ulcers 
heul, leaving an indelible cicatrix. At Aleppo the disease in ascribed to bad 
vftter. Where there is one tumor it is said to be the male, that which iji 



FURUNCULAR AFFECTIONB. Ill 

surrounded by seTend smaller ones is called the female. The disease is pain- 
less ; it never kills, and is indolent in its course. 

Now, all of the last three described diseases, it will be observed, bear close 
resemblance the one to the other. They reaily seem to have some of the 
characters of disease directly produced by external influ'ences, as the bites of 
insects. But there is no evidence that they are so produced. The treatment 
is the same in all cases — viz., that stated under Biskra Bouton. 

Cochin China Ulcer. — In the Zhiblin Medical Press, May 21, 1862 
(from Gaz, des H6p.)y it is stated that M. Kochard, Chirurgien-en-chef of 
the French navy, describes an endemic form of disease which attacked some 
of the French in China. The debility consequent upon the mal-action of the 
climate predisposes to it. It is prevalent especially in wet seasons, and 
appears to be uninfluenced by age, sex, or constitution. It is non-contagious. 
The disease consists of ulceration, which follows some lesion of the skin, often 
the most trivial, in those out of health. The lower limbs are chiefly attacked, 
and particularly the parts about the ankle and instep. M. Rochard has 
never seen it attack the plantar surface. Generally the ulcer is solitary, 
but the disease may attack both legs. The ulcer is usually two inches and 
more in diameter, and may extend more or less, or completely round the leg. 
Its shape is always angular. It does not usually j>enetrate more deeply than 
the skin and cellular tissue : it may, however, attack the muscles, and even 
bones, producing caries. The progress of the disease is rapid. First of all, 
some lesion occurs, then a red areola makes its appearance, quickly fol- 
lowed by ulceration, pain, and, by-and-by, insensibility. After a time the 
ulcer stops in its increase, gets clean, is covei*ed by a pultaceous scab, that is 
snbsequently thrown off and often re-formed, together with sanious discharge. 
Some cases demand amputation ; in others, attempts at repair are made, and 
change of air cures the patient. Sometimes the disease becomes chronic. 
At Brest Hospital the *' ulcers presented a depressed, uneven base, traversed 
by deep red longitudinal sti*eaks, consisting of small anastomosing blood- ves- 
sels, having between them yellowish lines of pultaceous aspect.'' The edges 
were hard, irregular, the skin around wrinkled, and anaesthesia was noticed 
in the parts around the sore, — in one case complete anaesthesia of the dor- 
sum and plantar surface of foot, even to red-hot iron. No cure has yet been 
made out. 



CHAPTER XI. 

BULLOUS DISEASES — HERPES, PEMPHIGUS. 

Under this head are included the diseases which are especially characterized 
by the occurrence of bullae. Willan described a bulla or bleb as " a large 
portion of the cuticle detached from the skin by the interposition of a trans- 
pai'ent watery fluid." In fact a bulla is a large vesicle. It will be seen that 
in the wide sense of the term several diseases are really bullous, such as ery- 
sipelas, hei-pes, pemphigus, rupia, eczema of the fingers, and impetigo con- 
tagiosa. But there are only two that really rank under the term Bullous 

i, e., herpes and pemphigus. Erysipelas belongs to the distinct class of zymo- 
tic diseases ; rupia is syphilitic, and grouped under that head ; the bulla 
produced by the coalescence of vesicles in eczemais accidental and secondary; 
and in impetigo contagiosa, the primary stage is a vesicle, the secretion is 
sero-purulent, and the general behavior and outward aspect are those of an 
impetigo. Besides, herpes and pemphigus are peculiar and alike in regard 
to the influence of the nervous system in their production. Therefore, true 
bullous diseases, or those which are probably of neurotic origin, and in which 
the bulks are primary, with transparent contents, are herpes and pemphigus. 

HERPES. 

This disease is characterized by the presence of vesicles larger than those 
of eczema, distinct from each other, mostly chambered and seated upon an 
inflamed base ; these large vesicles, or small bullaa (bullula?), are general! j 
tolerably few, they do not rupture, as the rule, but their contents, which are 
alkaline or neutral when clear, and slightly acid when turbid, after becoming 
opaque di8aj)pear by resorption, but now and then by rupture and defdcca- 
tion into light browninh scabs. The bullulie last about seven or eight daya. 
The disease is mostly accompanied by sensations of heat, tension, and burn- 
ing, which indeed are felt to a greater or less extent before the appearance of 
the eruption ; occasionally sevei-e neuralgic pains occur before, together with, 
or after, the eruptive stage. This is particularly the case in wliat is called 
Herpes zoster, or shingles. Writers generally divide herpes into two groups, — 
the phlyctenoidy including the disease as it generally occurs about the body 
(her]>es phlyctenodes) ; with certain local varieties — H. labialis, palpebralis, 
nasalis, auricularis, and herpes zoster ; and the circinate, including herpes 
circinatus, and herpes irris. 

1. Pfdyctenoid group, — Herpes pMyctenodes occurs in any part of the 
body, and its description will apply to all the local varieties. It commences 
with a sense of local heat and inflammation, with some erythema ; u{)on this 



whii 
otH 

m 



nrise round grouped veiucles, from ten to tw^uty, in patches the uze of 
six{it.>nce to a five-shilling piece, mirrouitded bj a red areola : tberft are gene- 
rally Beveml of these pstoheii; tliey mostly occur abimt the iaeej amis, neck, 
and upper limbs. Tlie eontenta of the vesicles, at first transparent, become 
niilky, then quickly disappear ; the vesicles ahrivol, and scabs remain ; the 
smarting heat and teuaiou also tiubnide; the disease lasts ten daya or more; 
the veudcs get to their height in two or three days, and dry up on tlie sev- 
enth or eighth. WLeu rented about the lipH, the disease is named If. labi/iti». 
The patch here is small, and generally the bulluls not over-develojied. It 
commences a* a " cold," with pyrexia, ibc. ; then the lofal heat, smarting, 
and tension are followed hy a pateli of herpes, with about six or eight 
veaicles. Herj>es affects the mucous membraiie of the pliurynx and palate. 
It i* common after catarrh — of which it is probably a definite part — tyjihoid, 
remittent, and intermittent fevers, cerebro-spinal meningitis, pneumonia. 
Herpes occurring under these circuniBtMices, is said to bo Ki/niplomatii; as 
conlmsted with the more genei-al Uliojialhie forma. // prajtutialui ia often 
syphilitic; in simple cases, the )>atch scales over in a week or so; tlie scabs 
f»ll oif, leaving little uloers the siie of pinu'dieads or more, which quickly 
'puce being irritable and red. If syphilitic, there are successive 
crops; the prepuce gets hard, and iudurateil about the Seat of tlie herpes; 
MitJon is sometimes jiainful. The mucous surface is more or less irriUble, 
igin from buliulio clear; the bullat give place to little ulcerations, 
close together, and quickly scab over ; in other cases, the vesicles 
llwrt, desiccate, and scale over; the little crusts foil off, leaving littlB pit«, 
which presently heal. _//. ^o»(«r, sotm, or ahin(flet, jiossesses the characters 
of II. phlyct«nodes, hut derives its special name from the peculiar manner 
which it tends to encircle one-half of the body tike a girdle. It is really H. 
but as it has some peculiarities in i-egard to distribution, I 
give a special description of it. It follows the course of one or moi-e 
the cutaneous nerves, generally stopiiing short at the median line before 
1, Uiough it may cross this point, and in this matter the experi- 
ence of Hchra, Wilsou, Startin, Hutcliinson, and myself agrees. It gene- 
rally olfects the trunk, but may attack (he face, the shoulder, the belly, or 
apper part of the thigh ; the right side more than the left. Of 178 cases 
collected by Barensprung, in 101 the herpes was on the right side. It is 
tnost common in the young; of about equal frequency in the two sexes, and 
occurs partictdarly during chaugcofwcatliBr. It see m« on some rare occasions 
to be almost epidemic. It is an acute disease, of de6nite duration, lasting 
about fourteen to twenty daya. The iiatient often ails a few days before 
eruption appears, is feverish, out of sorts, complains of headache, shiv- 
perhaps pain in the aide, which may lie veiy acute and of neuralgic 
; presently patches of erythema apf^^ FAi4(^rCa-at,M0|k^ close exami- 
1, a number of little white poing(j^Jip^»iui*liU^hM'g«inU> buliulw, 
kpH coalescing and forming distinct bulli^_ they_iiT« tense alittcoirtttiri'' 
serosity; iji four or five daya tho^vpsiclefl'beebme'^AHlallj'aiiplied, 
8 oW u -not to be remopsd from, Ihe 

Utrar,, r,,'^ 6y „„j j,er«m or 



114 HERPES. 

flaccid, the contents becoming turbid and dark ; at the same time the red 
blush fades, and the patch scabs over ; the crusts disappear in ten days or 
so, leaving dark red stains. The changes are not completed at the same 
time over the whole area of the patch, but are later in taking place in one 
part than another — hence travel, as it were, over the surface; conse- 
quently, several aspects or stages may be noticed in the same subject. In 
some rare cases, tlie H. zoster may ulcerate, or even become gangrenous. 
Pain may be a very prominent symptom ; it may be lancinating, smarting, 
or burning. The convalescence tinds the patient weak and neuralgic. The 
scars are not lost for some time. The diseane rarely occurs twice in a life- 
time. It is usual to make certain varieties of zona or shingles. Roughly 
stated, they are Z. capitis, faciei, nuchse, brachialis, pectoralis, abdominalisy 
and femoralis. It is as well to know tliat the eruption follows the course 
of distribution of certain nerves : the trigeminal in H. facialis, the labial 
branch in H. labialis, &c, <&c. When the limbs are attacked, and they are 
now and then, the line of eruption corresponds to that of the long axis of 
the limb ; the eruption does not encircle the limb. A want of knowledge 
in this respect I have known to mislead. If we compare the various forma 
of herpes phlyctenodes, we find that they are not diiferent, save in seat and 
extent. The herpes of the nose, mouth, and ear are identical, save in the 
part attacked. In zoster, there is not one patch as a rule, but a line of 
eruption often made up, however, of several patches ; the main feature be- 
ing the unilateral distribution. 

In the second, or circinate group, authors place two diseases : H. circi* 
natus and H. iiis. Under the term herpes circinatus two totally distinct 
things have been classed, the one parasitic, the other not. In ordinary 
herpes phlyctenodes the whole area of the portion of skin included by the 
outer edge of the diseased patch presents the heq)etic aspect ; there is no 
clear centre ; but in certain cases there may be a ring of bullulse inclosing 
a portion of unaflected skin ; the ring itself in diameter varies from one- 
twelfth to a quarter of an inch, and is made up of a red base, upon which 
are distinct buUulw, or large vesicles, giving place to subsequent scabbing; 
the diameter of the whole ])atch varying from half an inch to two inches, 
or even more. This is a truly herpetic disease ; it has a short and definite 
course, identical with that of ordinary herpes phlyctenodes. I have seen it 
on the neck, face, and forehead in non -syphilitic, and again in syphilitic 
subjects, becoming chronic, and being cured by syphilitic remedies in the 
latter. ^ 

The syphilitic form is symmetrical and chronic^ and accompanied by 
special concomitant evidences of syphilitic infection ; the other, or jmrasitic 
form of herpes circinatus, which I have ventured to call tinea circinata, is 
the ordinary ringworm of the body. It commences as a red 8j>ot, which 
enlarges in circumference, the central part getting paler or gradually recov- 
ering its natural ap{>earance. There are various degrees of this disease. 
There may be a circular erythematous patch, which is more or less scaly. 



115 

biit ia not covei'ed by anything Hke cniats — in fact, a (lesquauintiiig (.ery- 
thema. In other cases, at the extending edge vesicles may be plainly visi- 
ble, and the centre may clear; in other cases the centre may be iinaflBCt«<l, 
and the extending disease uppear hh a. red ring inclosing a pale centre, the 
edge of the ling presenting a. pnjiular or veoicular aspect. This of course 
npproacbes moat closely t*} the true hei'pes circinatuB. I have seen tinea 
cirriiiAtit develop rapidly as a largish patch, with Well-develoiied Tesicles, 
&ii<l then look veiy mnch like herpes phylc ten odes ; but in nil these cases 
tlie origin from a smftll red spot, the papulation or vesiculation of the 
extending edge, the clearing of the eeutre, the slight desi^imination, should 
at once decide the nature of the disease. The microscope should be used if 
there ia a. suspicion of parusite, and in any circulnr eruption which has a fui^ 
l\iraceous deRquainatiun. Tlie disease, too, lacks altogether the deliniteness 
tm to outiiet and duration, of tnie hui-jies. The cause isthe growth and irrita- 
tion uf a funguH, and it is eway to see that tfafi aspect of the disease will vary 
with the luxuriance of the parasite and the condition of healtli of tlie attacked. 
I hojie the nsme tiuen circinata will b« given tc this ringworm of the sur- 
taw, and it will not in fiiture be confounded with hei-pea, with wliioli it has 
only a similarity in external apjiearance. With regard to herpes iris I have 
little to say, as I know little about it. Two or three oiuii-.s have conie under 
my care ; tliey occurred on the back oF the hand in elderly people. The 
disease consists of a herpetic circular patch made up of concentric rings, 
there being generally a distinct vesicle in the centre. It ia an unimportant 



iety. I would remark that the dii 
iaf» of herpes is to me unnecessary. 
Th« Patholofft/ of /TerpM.— There ; 

I to explain satisfactorily the 
ineoted with a perversion of the ni 

) clinical facts have now been 
; they are — 1. The constAut 



1 into p/djfclenoid and arciTtate 



a little donbt but tliat we are on the 
e of herpes. Tliat it ia closely 
■veB going to the aifected part is ceilain. 
nifficiently demonstrated, especially in 
aiun'ence of neuralgic symptoms prior 
P tim develo]iment of herpes. Some of the most intense cases of '* pleuro- 
* are connected with zoster, and the pain is speedily relieved by the 
outbreak of eruption. A very remai'kable case will be found recorded in 
the Lancet for August 34th, 1667, in conuection with a gouty diathesis, 
ahowiijg the connection in ordinary herjjes between pain and eruption. 2. 
f "iIAe Becond fact is, the exact coii'espondence as to site of herpetic eruption 
b portions of surface supplied by cei'tnin nerves, and the development of 
I ernjrtion in the course of nerves. To take the last point specially, 
r of tlie chest will make its upi>ear!ince frequently in the part< sup|>lied 
e posterior cutaneous branches of the intercostal nerves, then in that 
nlsbed by the anterior, und so on. With regard to the other point, 
ich evidwice bus been put on recoi'd. Perhaps the most striking ease is 
t recorded by Mr. Paget, iu which herpes affected the parts supplied by 
) infr&-orbitAl, the anterior dental, and the anterior palatine branches of 
e miperior maxillary nerve. After catcliiugcold, the patient was attacked 



116 HERPE9. ^^^H 

on tiie tbird i\ny with bei-pes of the cheek, side of nose, the upper lw^^^| 
paJate, niid. buccal membrane. The final results were in some respecta ?■- 
markable, and in keeping with the explanation as to the ijupHcatioB of the 
n^rve tnmkR. A bicuspid fell out on the sixth day, a second on the seveoth, 
and lat«r still the canine and two incisors, whilst the alveolus in part ne- 
crosed. In tlie herpes ophthalmicuB, so fully referred to by Mr. Hutctiu- 
son, the same truth has been illustrated in a very remarkable way. All 
these facts clearly show that the nervouH system determinea the seat of tho 
eruption. Then as to the exact causation. In almost all casen we uv en- 
abled to iindemtaiid how it is that irritation is reflected along the nerre 
trunks, going to the exact locality of the herpetic eruptiou. When CMtarrfa 
afievts the sensitive mucous meinbraiie of the air-passiLges, the occurrenoe 
of herpes of the lip or nose can i*eadi1y be understood ; the play of cold air 
(chilling), or the dii'eet application of cold to a heated sur&ce, will acconut 
for the appearance of herpes phljctenodes ; herpes prteputialis has come on 
after an emission ; afl«r connection regularly, so as to leave no doubt a» to 
the co-relation ; and after other iriitAtion of the urethral mucous uiembnuw. 
The passage of a catheter has before now been followed by rigor and IrUbI 
herjies. There is no great difficulty in admitting this latt«r occunenoK 
Tlie only ]>'>iut upon which we retjuire enlightenment is that which omh 
oems the why and wherefore of the reflection to the nerves that go tc the 
Up. Gerhardt ubHerves that the group of diseaBeH in which zoster of the 
face occurs ia remarkable " by the frequency of an initial rigor or the occur- 
rence of an increase of temi>erature even to 32° Ileaumui*, on the first day." 
He thinks that the irritation must be caused by the followuig [>eculiarity 
of the fifth nerve: "The branches run through narrow bony canals along 
with small arteries : these arteries contract in the initial rigor, but then 
liUate, and their abnormal size creates a pressure on the brunches of tho 
trigeminus and the sympathetic. Tlie cjccasional result is the occurrencw of 
a vesicular eruption. Wlien this has once occurred an accommodation 
takes place in virtue of which a second attack of febrile dilatation of tho 
vessels does not irritate the vaso-motor fibres so as to cause an eruptiou." 
It is cuiioUB that in intci-mitteut fever herpes only occurs once, and it is 
held generally between tlie second and third lit. 

Pudendal herjies follows vaginal irril«tion likewise. In the case of hetpM 
EOBt«r moi'e infonuation is needed : that the nerve trunks are disordend 
tliere is little doubt, and here, as in other cases, this is followed by bypet^ 
»mia and vesiculation. There is no reason why a cold should not ^ve riw) 
to KOst«r. But zoster is said to occur only once in a lifetime, one shielding 
from ft second attack, and cold, chilling of the surface and the like, are oon- 
stantly happening. Hence a good deal more clinical obHervation is nece*- 
nary absolutely to veiify this opinion. But other forms of herpes occur re- 
peatedly in the same subject — herpes labialis and pri^putialia ; and this dixw 
not at all militate against the pai-t assigned the nerves iu the production of 
the disease, or prove that loster is different in nature from the mora-OM^H 



HERPES. 117 

mon forms. It is also easy to see that emotioual disturbance, mental dis- 
tress, may also play an important part in the causation of herpes. But the 
typical mode of production is seen in labial herpes, where initation of the 
mucous membrane of the air passages is reflected upon the nerves going to 
the lip, giving rise to hypenemia and vesiculation. It should be mention- 
4d that herpes zoster has been observed to occur during the exhibition of 
arsenic. 

Lastly, in regard to the pathology of hei*{>es as a whole, I may state that 
the disease presents in many of its features a family likeness to the exan- 
themata, as observed by Willan. It has a definite duration ; it is anteced- 
ed by general pyrexial symptoms, presents eruptive phenomena which are 
not successive, but which go through stages of maturation and decline, as in 
the eruptive fevers. 

The IHaffnosU, — Herpes cannot well be confounded with any other disease. 
The red base, upon which a few large clustered distinct multilocular vesicles 
(bulluln), which are larger than those of eczema, and smaller than pem- 
phigus, are seated, with the acute regular course, of definite and short dura- 
tion, its non-secretory aspect, and the frequent presence of neuralgic pheno- 
mena, and ordinarily of smarting, heat, and tension, are diagnostic. Erysi- 
pelas may resemble H. zoster ; but it is not unilateral, the bulla) are large, 
the redness is accompanied by swelling, the edge of the blush is well defin- 
ed, and rigors are present. 

Prognosis. — There is no anxiety whatever to be entertained save in the 
occurrence of zoster in persons of feeble constitution in advancing or ad- 
vanced life. In this case great debility, and ulceration in the site of the 
herpetic patch, may result, and the special care of the physician will be 
needed to sustain the powers of the patient. 

The Treatment. — Usually the only thing necessary in the treatment of 
herpes is to protect the eruption from being iriitated by the clothes of the 
patient, and other external influences. This arises of course from the faot 
that herpes is a disease of definite duration, and that the eruption is, so to 
speak, its " explosion.^' The temporary nerve paresis, of acute production, 
therein spends itself, and no cause exists for the continuance of the disease ; 
and so we find that when once the eruption is *^ out '^ i*elief from pain, neu- 
ralgia, and the like, is obtained, and the healing process at once commences 
in the affected skin. We only need therefore to help the reparative process 
set agoing by Nature. 

I use generally a lotion of oxide of zinc and acetate of lead with glycerine 
locally, and cover the patch over with a layer of amadou, or two or three 
layers of lint, in the early stage ; and subsequently, when desiccation has 
taken place, apply a cerate composed of elder-flower ointment an ounce, 
lead lotion a dr.»chm, and prepared calamine powder two scruples ; but 
glycerine of tannin is e<|ually good, and indeed may be used from the com- 
mencement. In zoster the eruption may be oiled over, and then dredged 
with flour freely, placing upon this a layer of cotton wool. The great thing 



118 PEMPHIGUS. 

is to avoid too much meddling. In some cases neuralgic pains are very se- 
vere ; here poppy fomentations : equal parts of the linimentum belladonna 
F. B., and linimentum camphorsa, or olive oil : chloroform : morphia dress- 
ing, or, if required, the hypodermic injection of aconite and morphia, are 
necessary. And under these circumstances internal remedies are to be used 
— quinine especially in full and repeated doses, ammonia and bark, and aco- 
nite or opium, as the case may be. After herpes zoster I always advise a 
course of tonics — the mineral acids and quinine with slight aperients. In 
certain other cases there may be special indications for general treatment, 
either by reason of pyrexia, or the debility of old age, bark and port wine 
and plenty of nourishing food being here requisite. Should ulceration oc- 
cur in zoster, nitric acid and opium lotion, or a weak solution of caustic 
(grs. X. — XX.) in nitric ether ( 3 j.) will be sei-vicable. In herpes iris nothing 
8|)ecial is called for. In those cases which I have seen there was nervoas 
debility present, and the mineral acids with bitters, and some astringent 
application locally, acted satisfactorily. Of course when herpetic eruptions 
occur in the course of catarrh or fevers, the proper treatment is that which 
is fitting for the general disease. See formulas 66 A, 71, 32, 62. 

PEMPHIGUS. 

This disease is characterized as regards eruption by the appearance of lit- 
tie sepai*ate blebs usually grouped in threes or fours, seated upon slightly 
inflamed bases, which by enlargement they quickly cover. These blebs may 
attain a size varying between that of a pea and a hen's egg. They are dis- 
tended with fluid, which is at first very transparent, but soon becomes milky, 
and is quickly reabsorbed, or the blebs or bullae simply shrivel, the distend- 
ed globe becoming flaccid. Very often the blebs burst in a few days, and 
then the contained fluid dries into crusts of lamellar aspect, beneath which 
is the slightest ulceration ; the contents are sometimes sanguinolent ; the 
bullae are generally successive ; they arise in the course of a few hours; 
their outline is generally round or oval ; there may be one or many, and 
they may be confluent, but are iisually discrete. Now and then a species of 
false membrane is contained in the bullfe. The reaction of the fluid is gen- 
erally alkaline, but with turbidity comes acidity. The local symptoms are, 
slight itching and smarting at the outset, and more or less soreness. The 
healing process in pemphigus is sometimes tardy, a thin ichor being secret- 
ed by the surface originally blebbed, and so a quasi-imi)etiginous crust is 
often produced. The disease attacks all parts of the body — rarely the head, 
palms of the hands, or soles of the feet ; sometimes, however, the mucous 
surfaces— ex., the intestines, vagina, &c. 

Now this general description applies to all varieties about which much 
unnecessary fuss has l>een made. The term pompholyx was originally used 
to denote the chronic and most indolent form of pemphigus, but the two 
terms are now used in the same genenil sense. 

Pemphigus is almost always chronic, but there is an acute form ; and we 



PEMPHIGUS. 119 

have therefore, in accordance with moBt authors, to make two groups, cusute 
and chronic. 

Acute pemphigu8 is seen in children, and is synonymous with pemphigus 
neonatorum. Now the greatest doubt exists as to the nature of this aflfec- 
tion. According to Dr. Steffen, there are three forms — (1) pemphigus oc- 
curring in children apparently healthy and ending favorably ; (2) pemphi- 
gus in children who have been badly nourished, or who have fallen into a 
state of marasmus, and in whom it is therefore the result of cachexia ; and 
(3) sjrphilitic pemphigus. Under the second head would therefore rank 
the pemphigus gangraenosus which occurs amongst the ill-fed Irish, and so 
named by Dr. Whitley Stokes. From all that I can gather, and basing my 
observations on such an epidemic as tliat wl^ich occurred in the General 
Lying-io Hospital in 1834-5, it seems clear to me that there is a non-syphi- 
litic and a syphilitic form. When it is epidemic and occurs amongst the 
children in a lying-in institution, it seems to me to result more from the 
operation of acute blood-poisoning, such as that of puerperal fever. Appar- 
ently healthy children are seized with severe constitutional symptoms, the skin 
is livid, the areola dai*k ; the contents of the bull» are fcetid ; the ulcera- 
tion is unhealthy, deep ; its surface is dark, blackish, and exudes an ichorous 
matter; the edges are livid, shreddy, so that large circular, depressed, 
black, gangrenous ulcers, acutely produced, are present. The feet and 
hands may be affected, but also the limbs, the genital parts, the abdomen — 
even the mucous surfaces and head ; death occuiTing about the tenth or 
twelfth day. In other cases, in bad fed and overcrowded children, the dis- 
ease may not be so severe, but presents much the same kind of changes. 
There is a purplish base to the bullae, sanguinolent contents, ichorous dis- 
charge, and a good deal of sloughing and gangrene ; the disease being pro- 
pagated by successive crops for weeks, and the child often dying, worn out 
by irritative fever and exhaustion. 

Pemphigus (neonatoinim) acutus is also syphilitic, and occurs as a conse- 
quence of the cachexia of that disease. It occurs, not as an epidemic, but 
in connection with other symptoms of congenital syphilis, and is well-marked 
about the hands and feet soon after birth ; it may give lise to deep ulcera- 
tion. 

Ordinary pemphigus has sometimes an acutish aspect, there may be head- 
ache and pyrexia ; in a couple of days or so, little red points ap[)ear ; and 
upon these little bullas form, which rapidly increase and fill : there may be 
an areola ; all depends upon the increase of the bullie. The latter and the 
red blush increase together, but generally not pari passu, for the bulla over- 
takes the areola and hides it from view. In two or three days more the 
bull» burst, a raw surface is left ; but this scabs over : at first the incrus- 
tation is yellow, then brownish. The bullae seen on the limbs and trunk are 
successive, and so prolong the disease for some weeks. When the disease 
occurs in a more chronic form, it has been called I^, diuthvuSy the two 
together making up P, wdgaris. Sometimes there is but one bulla devo- 



120 PEMPHIGUS. 

loped at a time ; it is large, bursts in one or two days, crusts over, and 
disappears ; then another develops. It is chiefly seen in old people who 
are debilitated. The bulla appears after a little tingling about the ankle or 
the wrist. Five or six bullsa in all show themselves. This form is styled 
2yemphiyu8 aolitarius. All these fomis may occur in children and young 
persons, as well as adults. There are two more varieties. In one, pem- 
phigus foliaceus, the disease commences on the front part of the chest 
by a single bulla, and by the development of others around, spreads over 
the whole surface, the bullae being more or less imperfectly formed ; the 
skin is red in many places, but there is not much infiltration ; itching is 
not severe. After the bullae form, large yellowish squamae are produced, 
with more or less desquamation ; the scales, which may be large, are the 
remains of imperfectly-formed bullae, and are free at their margins, and they 
are reproduced very rapidly. The bullae are successive and confluent; 
oftentimes the skin exhales an offensive odor. The scales have been de- 
scribed as resembling French pastry, pieces of parchment, or papyrus, and 
vary in size from three-quarters of an inch to two inches. It is often a fatal 
form of disease, death being ushered in by irritation of the mucous surfJEu^es 
and dropsy, in old people who are weak and out of health. 

Lastly, there is a form in which the characters of prurigo and pemphigus 
are intermingled, to which the term pemphtgtis pruriginosua is given. 
The bullae are small and not well formed, though numerous, and the pruri- 
ginous itching is most distressing. Microscopical examination has detected 
in the fluid of pemphigus what seem to be mucus and pus-corpuscles, but 
are thought to be newly-fonned epidermal cells. Bamberger declares that 
there is a great deficiency of solids, especially albumen, in the blood, and of 
phosphoiic acid in the urine. 

Cause. — Little is understood in regard to the exact causation of pemphi- 
gus. It is well known that general debility, intem[>erance, cold, gastro-in- 
testinal disturbance, moral emotion, cachexia, and bad living, often seem to 
evoke the disease, but what we want to know is the immediate and proxi- 
mate cause. From all that has been written, it would seem that the nervous 
system is specially concerned in the matter ; and that it is the channel bj 
which morbid influences that result in the eruption are conveyed. In many 
cases an appreciable disorder of it precedes the eruption. Dr. Hussell has 
remarked this. Tliat there is some serious constitutional disturbance, 
is shown by the fact that those who have died of the disease have been 
found to have fatty livers, and amyloid changes in other organs. Compare 
the case of leprosy. We have serious deterioriation of the general health, 
in which the nervous system is implicated, and one of the very first evi- 
dences of the latter is the production of bullae about the skin prior to, or in 
connection with, the occurrence of anaesthesia, which we know is due to 
distinct disease in the nerve trunks. This seems to me to throw consider- 
able light by analogy on the veritable mode of production of the eruption 
of pemphigus. The deficiency of solids in the blood, and of phosphates in 



PEMPHIGUS. 121 

the urine, indicates a condition of blood which must disorder the nervous 
system, and may fully account for the dise^ase. Now iu herpes, we have 
the effect as it were of a temporary or sudden, or non-persistent influence ; 
in pemphigus, we have a persistent and slowly-evolved influence, reflected 
through the nervous system upon the surface, hence in the one case a dis- 
ease of short' and definite duration, in the other a chronic malady. 

But some different explanation is needed in regard to acute pemphigus. 
In this instance, it is possible to conceive that the nervous system is par- 
ticularly involved, although the whole body is affected seriously by septic 
poison, absorbed from without. It must be remembered that bullae occur 
in erysipelas, and here the burning heat, the evidently great and sudden 
distention of the vessels of the affected part, and the consequent rapid effu- 
sion, show that the nervous control over the vessels is specially at fault. 
If the acute effusion were due to the fact that the blood was of such a 
quality that it would not pass through the capillaries, we should expect to 
have bull89 in all acute specific diseases. What I wish to emphasize is the 
fact that the morbid influences that cause the cutaneous changes in pem- 
phigus seem to operate immediately, not through the blood, but the nervous 
tract ; why the nervous system specially is another question, beyond our 
knowledge at present. 

Prognosis. — The cure is not rapid, but slow ; recurrence of the disease 
is frequent. In old people, where the disease is general, and in children 
with much ulceration, the issue of the case is often unfavorable. The g(^ne- 
ral condition of the patient is to be our guide, and in these cases a cautious 
opinion is always needed. 

Diagnosis. — Pemphigus can scarcely be confounded with anything else, 
the bull» are so appreciable a sign. In eczema of the hands, bullie may be 
produced secondarily by the confluence of vesicles, but their origin is clear- 
ly traceable, and co-existent eczema is to be found elsewhere. Pemphigus 
is rare on the hands and fingers, per se. Greneral eczema and P. foliaceus 
should not be confounded ; in the latter the bullsB are present, the scales 
are larger and peculiar, the skin is not infiltrated. 

In ecthyma cachecticum the pustules contain bloody fluid ; there are no 
true bullae ; the crusts are thick and dirty ; the ulceration is deep ; the dis- 
eane is pustular. In rupia, the bullae are smaller and flatter, the contents 
sanious, the crusts thick, dark, prominent — cockle-shell like ; the ulceration 
beneath deep. Pemphigus foliaceus resembles pityriasis rubra ; but in the 
latter there is no history of bullae ; the scales are altogether smaller ; there 
is no characteristic odor, no wasting of flesh. 

Sometimes in impetigo contagiosa the bullae become somewhat large, but 
they are never distended as in pemphigus, but flat ; the contents soon be- 
come purulent, and flat yellow scabs form, which are chaiucterLstic. It is 
clearly pustular. 

Treatment. — In the acute forms the disease must be treated as a typhoid 
diaeasey an aperient to begin, then salines, with ammonia, unstimulating 



122 PEMPHIGUS. 

nouiishment — strong broth — and as soon as the pyrexia is at all subdned, 
tonics sliould at once be had recourse to ; in childi*en, chlorate of potash 
and quinine, with wine, will be necessary ; in the syphilitic variety much 
the same line must be followed as regards the child, whilst the mother 
should be well toned up and well fed. Slight mercurial inunction in chil- 
dren who are in sufficiently good condition to bear it, should be employed. 
Then as regards local measures, weak solutions of permanganate of potash 
and carbolic acid, with the use of absorbent powders ; and presently, when 
the sores are cleanei-, weak nitric acid lotion seems to be the best. An oint- 
ment of scrophularia nodosa is advised by Dr. Stokes, in the gangrenooi 
variety. In tlie chronic foims, good diet, with quinine, the mineral adds 
and arsenic, are the remedies usually employed internally. In many of the 
cases of pemphigus that I have seen, there has been a deficiency of proper 
meat in the diet, and a good deal of worry, the two together inducing an 
auaemiated and exhausted condition. In these instances, plenty of good 
food, with the mineral acids and cod-liver oil, and a due attention to elimi- 
nation, has sufficed for the ciire. We may generally find some cause of de- 
bility in our patients, and it is necessary that we treat that specially. I 
think, in many cases, that aperients combined with tonics are called for. If 
we feed up a half-starved individual, or give tonics to a debilitated subject^ 
whose waste products have already overcharged the blood, without taking 
care that proper emunctory work is carried on, we may even increase the 
disease. I have seen this, and therefore I think it important to attend to 
the proper elimination of effete products from the system, through the 
bowels and the kidneys. In the moi*e quiescent forms, arsenic seems to be 
as good I'emedy as any. I am not certain that phosphorus with quinine is 
not a good treatment (with a thii-ty-second part of a grain of the former). 
In old people, pemphigus may be regarded as the hint of a ** bi*eak-up." In 
such cases, a nourishing diet, quietude, and bark and acid are the best re- 
medies. Locally, in these chronic forms, we may let out the fiuid from the 
bulhe, ap])ly some inert powder, such as lycopodium ; subsequently weak 
astringent lotions, siich as alum, tannin, zinc, or even ointments of zinc; 
and if the sores do not heal, use a solution of nitrate of silver, gr. iij. vel iv. 

to 3J- 

In the pruriginous variety, conium and aconite, or quinine, internally, 

with alkaline baths, or cyanide of potassium lotion, may be employed. A 
very good application, to cool and comfort the surface in all cases, is a mix- 
ture of common whitening, glycerine, and water, made into a thinnish paste, 
and spread over the suiface by means of a brush. 



• CHAPTER XII. 

ALPH0U8 DISEASE (LEPRA VULGARIS). 

This disease is characterized by hypersemia of the cutis, hypertrophy of 
the papillss of the skin and the epidermic cells, as shown by the free pro- 
duction of well-formed, whitish, epithelial scales, aggregated together, so as 
to form a more decided scaliness than in pityriasis. There in an entire ab- 
sence of any discharge, vesiculation, or pustulation throughout the whole 
course of the disease. It arises as a primary condition, and occurs in about 
seven per cent, of all cases. The eruption affects parts of the skin (by i)re- 
ference) whose epithelium is thick, especially the elbows and knees. It 
may be partial or general. At the outset the disease is attended by more 
or less pruritus ; the increase of the patches is by centrifugal growth, and 
there is oftentimes a slightly red margin : the surface beneath the scales is 
dull red and shining and papular ; the scales are shed, to bo. again replaced 
by othera ; in chronic cases the derma itself becomes very distinctly infil- 
trated and thickened. The general health is often apparently *good. The 
disease is non-contagious, runs a chronic course, and is very prone to recur- 
rence. 

The structure of the scales or squama) of lepra is peculiar ; if the under- 
surface be carefully examined it will be seen to be pitt^ or marked by lit- 
tle hollows, and these correspond to the enlarged papillte of the skin ; the 
adhesion of scales to the sui-face beneath is decided. The scales, placed 
under the microscope, are seen to be composed of epithelial cells only, matted 
together, well-formed, sometimes even enlarged ; many are flattened to- 
gether, so as to be almost fusiform, and this results from their rapid growth 
and close package. 

Lepra occurs as an hereditary disease. It attax^ka males more than fe- 
males, and is most common between the ages of fifteen and thirty. The 
sanguineous temperament is present in many cases. All classes of society 
are liable to it, and it is seen mostly in summer and winter. 

Psoriasis is the same disease as lepra, according to most writers, but Mr. 
Wilson applies the term to chronic sc^ly eczema. The varieties of lepra may 
be given in a very few words. It was the custom to apply the term psoriasis 
to the ordinary patches of the disease, and lepra to that variety in which the 
centre of the patch clears, and the disease takes the form of a rin(/. This 
distinction is not kept up now. 

Lepra begins by little minute spots of a whitish tint, made up of epi- 
deimic scales heaped together ; this is Lepra punctata. It usually affects 
the body and limbs. When the spots are larger they look like drops of 



^^^P 124 Aif Hove DiesAfiK. 

^^^H mortar, &Dii the diiii^aae is tUen called Tjtpya guttata ; it its sena ationl the 
^^^H ariiiii, breast, back, legs, and thighs. When the eruptiou occurs in paUrlieis 
^^^H about the size of a shilling or bo, we have I^epra Jinmmularia / it. is pro- 
^^^H duced sometimes br the coalescence of smaller spots. When the diseasu is 
^^^H in a still more developed coiidition it is tei-med jOepra diffvta. It often 
^^^H covers a large extent of surface, is alwiiys seen on tlie ellnwn And kneee ; 
^^^H the scales are well funned, the patches generally tliickeoed, and often 
^^^H cracked. When the ei-uption takas the form of bands, it is styled Ziepnt 
^^^H ffi/ralii. This is always due to the ruuuing together of circles ; the soalea 
^^^H are thin and speedily reproduced. This vai-iety is seen mostly in tlie back. 
^^^H Now lepra may pass through all these stages in one and the sauie subject, 
^^^H or the featui'es of one stags may be preserved iii individual cases. Then we 
^^^H have general {utoriasis or lepra, which may present the features of nny one of 
^^^H the varieties described. C'hi-onic, or Lepra inveterata, in which the patches 
^^^H are much thickened and cracked, the scales large, dry, and adherent : th« 
^^^1 patches may be hot and teudei-, and slight disehai'ge occur. Tliis is wfakt 
^^^H Pevei'gie called " psoriasis eczemateux." It prcttents the characters of lepra, 
^^^H and, in addition, the tendency to pour out a fluid secretion, whicli Htm 
^^^H into scales of rather larger size than those of psoriasis ; the surface beneath 
^^^H is red, and slightly moist ; it is seen about, the forearms and legs. The 
^^^H itohing and {Hiin are more marked tban in psoriaids. The disease is a mixture 
^^^H of lepra vidgaris and eczema. The nails may be opaque, brittle, worm- 
^^^H eaten. When the scales are very white, the term Lfpra alphoules is aome- 
^^^B times used. Occasionally the accumulation of scales takes place to an 
^^^H unusual extent : the scales ai-e hea,ped up so as to form crusts, something 
^^^H like those of nijiia. Pr. McCalt Anderson has given this the namo of 
^^^1 psoriasis rupioides. On removing tlie crust, a circular red surface is ex- 
^^^H posed, but it docs not " dischai^." There ia a tendency in this form of 
^^^H psoriasis apparently to the production of pus. 1 have seen onUnary lepix 
^^^H vulgaris assume tlie characters deecribed as nijiioid during convalescence 
^^^H from intercurrent measles, the debility consequent upon the latter favoring 
^^^H cell proliferation. I regnrd psoriasis rupioides as lepra modified by ca- 
^^^ chexia, in which there is a tendency to j'us formation. There is no ulcerative 
stage, and therefore the word rupioides is apt to mislead. Itching is only 
occasionally troublesome in lepra, and then it generally occurs at the otit- 

Iset. Tlie elevation of the patchcH of lepra varies, generally it is about tt 
line. It is customary to make certain local varieties. 
L. eapUin, — The head is the commonest seat of the disp^ane, next to tba 
elbows and the knees : the whole icalp may be affecfett, or there may ba 
only one or two small points of eniplion ; when extensive, tlic diseasa 
travels on to the forehead, forming a kind of fringe along it at the upper 
|)art. There ia co-existent disease elsewhere. The hair on the scalp tbina 
ont frequently. L. pnipi^mlia is seen at the outer angle of the eye; it is 
usually a part of more extensive disease in other parts ; there \n itching, 
BcalinesB, and the eye becomes irritated. L. lahiaiU occurs on the lo wtr 



ning 1 
the L 

K 



ALPBOirS DIBBABE. 1854 

iip mostly, and is often confounded with eczema ; the surface ia scaly, fis- 1 
HUred, puckered in toivardB the angle of the mouth, and reddish ; the scales 1 
are speedily reproduced, X, paliiiairia et plantarlt are important local I 
vtirieties. Tlie skin in the affected parts is thick, atid the aspect of the dis- I 
ease differs somewhat from the usual type. Jt may be limited to the centre I 
of the palm of the hand or sole of the foot, coming on gradually and run- I 
ning u clirouic course ; in other cases, conjoined to tlie typical disease on I 
knees or elbows. The patches are dry, harsh, thickened, discolored ; the 1 
is is not very marked, but the sujierficial layers peel off frotii time to I 
Presently the surface cracks and fissures, and healing is very tardy ; I 
ioiialty tlie surface bleeds. The muscular movenieiits of the bund are J 
pitiiiful. In other cases the disease runs a more acut« course ; the palm of I 
the hand is <|uiukly invaded over its entire surfaoe, aud the disease ma7 I 

.vel along the {>alniar as]>ect of the fingers ; the skin is red, " hot,'* I 

:ked and fissured ; as in the other case, It is sometimes att«&ded by I 

[1 the sole existing disease, it is probably always syphilitic. I 

Jjepra (or Paoriaaijt) unguium is mostly a complication of the inveterate I 
form of lepra, but may exist alone. Tlie nails (and sevei'al are usualljr 1 
aiTected) lose their polish, and soon become opaque, thickened, irregular, I 
and brittle ; they are then hstnired and discolored ui lines (fn)m dirt), their I 
matrix becoming scaly. The disease (lepra) also affects the scrotum and I 
prepuce ; the parts are swollen, red, hard, tender, scaly, fissured more or I 
loss, utid give exit to a thin secretion, which adds to the scaliiiess; thereaitt I 
pruritus, and the local mischief may be the sole, or jiait only, of I 
iral disease. I 

When lepra is in progress of cure, tbe scales lessen and the reddened el«> 1 
Vftted surface beneath comes more prominently into view, but this dimiuiahea I 
gradually till the eruption disappears, leaving oftentimes no trace of its I 
former presence behind. It may leave, however, pigmentary stains, the 1 
result of the congestion. It is in the disappeai-auce of patches of lepra that \ 
the) centre rapidly clears, and the ringed form or lepra circinata, or the lepra I 
of old authors, is produced. I 

Pallttilogif atul Caaae. — Hebra and some of the French writers hava I 
sought to ally lepra vulgaris to ecsema luid lichen, but this i-elation is utterly I 
negatived by the pathology of the disease. If a portion of akin affected by \ 
lepra be examined inicrosiJopicaUy it will be seen that tlie papHlie of the skin I 
are enlarged, tbe epidenniu cells of the ^[alpighian layer being specially well I 
developed. In addition, cell growths, resembling cuticular cells, are ub- I 
served along the course of the vessels running near to and into tlie papiUss, \ 
and these vessels are like the other structures, of larger si/e than natural — I 
in fact, hyperli-ophied. This new cell-growth is most abundant in the upper \ 
layers of the corium, and about tbe apices of the papillae, and here cells ars i 
piled togetlier into little heaps, and no doubt are pushed forward to form I 
the ordinary scales. Neumann, who has lately investigated this subject, I 
finds that tJie vascular twigs sent by th« vessels of the corium to the napilliB J 



126 ALPHOUS DI8EA8B. 

are peculiarly well-developed, spread over the entii*e area of the papillae, and 
even disposed in circles, so that the ^' cells " which are outside the TaRcular 
walls are arranged in horizontal lines, as well as parallel to the long axis of 
the papillee. As the vessels are so abundant, the whole stroma of the pa- 
pillae is filled with the cells which lie outside the vessels. Hence there is 
hypersemia of the cutLs, hypertrophy of the papillae as a whole, and an exces- 
sive formation of the cells which ordinarily go to form the epidermis, this 
cell proliferation commencing in the upper layer of the corium, and chiefly 
around the vessels of the papillae, and coming forward to the surface in the 
form of the white imbricated scales. Now these changes ai^e primary in 
lepra ; cell proliferation occurs to a varying extent, as the result of conges- 
tion in other diseases — but here they are different from those observed in 
lepra. The cell-gi*owth may exhibit an amoebiform character. This view of 
the pathology of lepra at once disengages the disease from all relationship 
with eczema. Then with regard to the cause — the circumstances that bring 
about this hyj)ei'trophous growth of the papillae and cuticular cells — little is 
known. The disease occurs oftentimes in those who seem quite robust and 
healthy, and a certain amount of constitutional vigor seems to be necessary 
to its development ; but I don't think they are sound in nutritive power. I 
agree with Dr. Anderson that there is very frequently some cause of debility 
present, ^' though this is quite incapable of calling forth the disease unless 
the predisposition exists." What that is is as yet a mystery. Over-lacta- 
tion, " overgrowth " in youths, mental worry, bad living, over-study, all pre- 
dispose to the occurrence of lepra. 

I^rognosts. — The disease always is difficult of cure and has a tendency to 
recur. The most obstinate cases are those of lepra nummularis of the back 
and buttocks, as far as I have seen, in which there is much elevation and 
thickening and deep redness, and lepra of the hands and feet. 

Diagnosis, — Red patches covei'ed over with white more or less silvery 
scaliness as a primary formation, without any history of discharge, are the 
main diagnostic points. Lepra may be confounded in its local varieties with 
pityriasis, lichen circumscriptus, eczema, tinea circinata, er3rthematoiis 
lupus, and, when general, with pemphigus foliaceus, pityriasis rubra, lichen 
ruber, and the squamous syphiloderm. Pityriasis is known by its thin^ 
branny scales, which freely exfoliate, and do not therefore form imbricated 
layers, the absence of all thickening or marked hyperaemia of the cutis. The 
diseased patch is not elevated, it does not feel thick and harsh, the elbows 
and knees are not specially affected. lAchen circumscriptus is an itchy 
disease; it is produced by the aggregation of papules. The scaliness is 
slight, and it does not attack the elbows and knees. The skin generally is 
thickened. JSczenui always has a history of ^' discharge.^^ Crusts, as dis- 
tinguished from scales, are present in the early stage, and therefore it is 
only in chronic eczema, when the epithelial formation is recovering itself, 
that any error can arise. In this the scales are mixed with blastema ; they 
are loosely attached and thin, not silvery white ; there is burning and itch- 



ALPIIOUB DISEASE. 127 

ing ; the disease is not seated at the elbows and knees. In tinea circinata 
there is a kind of scaliness, but it is rather a '^ fraying '' of the epidermis ; 
there is itching, a circular form, the centre is often pretty smooth whilst 
the outer edge is somewhat papular ; it is unsymmetrical, often vesiculating 
at the edge of the patch, and under the microscope the scales are seen to be 
composed of blastema and epithelial cells and fat, together with spores and 
often mycelium that has found its way among the mass ; and lastly, the dis- 
ease is contagious and may exist in several membera of a family. HJrytJie- 
tncUous lupus should not be confounded ; there is no true scalitiess, but 
deposit in the skin, with a tendency to loss of substance and scarring, a 
gelatinous look and a deep red color. The disease is mostly limited to the 
face, and occurs in strumous subjects, which is not the case in lepra. JPern- 
phigvs foliaceus is known from general psoriasis by the fact of its oiigin 
from bull89, tlie presence here and there of bullae, the absence of silvery im- 
bricated scales, and the presence of large flakes or lamellro, produced by the 
collapsed walls of the bullss, together with more or less secretion. Pitj/- 
riasis rubra has no thickening of the cutis, no papillary hypertrophy, but 
constant exfoliation of flakes, together with small scales. It is very general, 
attacking every jmrt of the body ; there is a peculiar yellow aspect about 
the disease well seen if the blood is pressed out of a portion of the afiected 
skin, and the hyperaemia is more generally and more perfectly marked. 
lAchen ruber is a papular disease. The confusion of JSquanioiis st/phih- 
derma is by no means unlikely. For the diagnosis see syphilitic diseases. 
Eczema may complicate lepra, then we have the characters of lepra plus 
those of eczema. This is the explanation of those cases of chronic disease 
which commence as lepra and presently exhibit more or less " discharge " 
and crusting. 

Treatment, — Lepra, as I have said, puzzles us by its occurrence in per- 
sons of apparent sound health, but there are exceptions to this rule. We 
find a woman becomes pregnant, gets some stomach derangement, out comes 
her old enemy, psoriasis ; another is nursing, she lives badly, presently suf- 
fers from hyperlactation — the disease ap])ears. A gentleman who has heavy 
headwork to do, is worried, anxious, and becomes aflected. A sei'vant gets 
very little fresh air and plenty of work to do — debility follows and psoriasis 
results. Another partakes too freely of wine or seasoned food, or is influ- 
enced by circumstances which give him a gouty or rheumatic habit, or occa- 
sion a temporary change from his ordinary quiet mode of life, and he, too, 
suffers. Now, in all these instances, the disorder of the general nutrition 
helps out the disease, a pre<lisposition to which exists in those who are 
attacked. Anything, in fact, which tends to lower the general tone of the 
system (the resistant power), is likely to conduce to the occurrence of the 
disease. 

Some of the best results I have obtained have been, in over-worked 
women, from the use of cod-liver oil, with steel, or quinine, or a course of 
the mineral acids. We must treat the patient rather than the disease. Now 



128 ALPHOUS DISEASE. 

it is the custom to regard arsenic as the only remedy for lepra. I cannot 
subscribe to this. Every case should be treated upon its merits. The 
specific treatment is rather local than general, and the idea which I have 
in regard to treatment, is to tone up the system generally, by removing 
causes and conditions of debility, and mal-assimilation, so as to enable Na- 
ture to bring back the mode of cell-growth in the skin, to its proper charac- 
ter. Hence in growing children I give iron, cod-liver oil, and plenty of 
• meat. In lactating women quinine, the mineral acids, good diet, and porter; 
in gouty and intemperate subjects, alkalies, and colchicum, or the mineral 
acids, as the case may be ; in over-worked men and women, change of scene 
and rest from fatigue if ])ossible. A full animal diet is often important in 
connection with tonics. Dysj>ep8ia should be carefully attended to. When- 
ever there is much hypersemia of the cutis, or any febrile symptoms, I use 
diuretics, and the best I have found is the acetate of potash, in half-drachm 
doses three times a day, with or without arsenic. Then, supposing that the 
geueiul state of the patient appears to be almost faultless, what is to be 
done ? Give specifics ? This is what we are recommended to do. The one 
specific is said to be ai-sonic. Whei*e the scaliness is free it does most good. 
If there be much hypera^mia, I combine it with alkalies. Dr. McOall Ander- 
son recommends carbonate of ammonia in large doses. Tincture of can- 
tharides has not been of much ser\'ice in my hands, nor have tar pills. 
Iron, cod-liver oil, mineral acids, and bitters, in the anaemiated, or ill-nour- 
ished, dyspepic, and strychnine and phosphorus, with large doses of dilute 
nitric acid, in subjects suffering from 7iervou8 debility, have proved moat 
successful. In old standing cases, where there is much thickening of the 
patches, a mercurial course is advisable, followed by tonics. The local 
treatment is ver}' important. Bearing in mind the morbid cell-growth, it 
is easy to conceive why tarry preparations act efficiently, and they are the 
i*emedies of general applicability and utility in lepra. When cases first 
come under treatment, or more properly in the early stages of lepra, and 
before tarry preparations are used, it is necessai'y, if there be inflammatory 
symptoms, that they be subdued by water dressing, alkaline and emollient 
baths, aperients, and diuretics. 

It is an important point not to stimulate the skin to too great a degree 
by outward applications, so long as the disease is increasing. This is a rule 
of some moment, inasmuch as the stimulation by tar or otherwise, may only 
increase the hyperemia and consequent spread of the disease. I am sure of 
this. When, therefore, the disease is actively increasing, the emollient, 
diuretic, and ai>erient ti*eatment should be first used. In all cases the scales, 
when abundant, should be removed by maceration, so that the applications 
may reach the real seat of the disease. 

If the disease is slight and localized to a few s|>ots only, we may at once 

begin with tany applications, for the scales are thereby removed sufficiently 

well. An ointment composed of olive oil 3 j«9pyroligncous oil of juniper 

3 ij.| and adeps ^ j., may be used night and morning. At the hospital I 



ALPH0U8 DISEASE. 129 

employ creasote six drops, mercurial ointment gi\ xv., and adeps 3 ij. 
Where the disease is more extensive, or the scales thickly covei-ing the 
patch, alkaline baths are to be employed (four ounces of carbonate of soda 
to each bath), the patient ** soaking" for some twenty minutes or so, or 
individual patches may be so^ned up with water-dressing, or glycerine 
plasma, and this is especially necessary in hardened spots of lepra about the 
hands and feet. Independently of its softening action, the alkaline bathing 
seems to exert some curative power. When the scales have ceased to form 
freely, a solution of nitrate of silver in ether (3ij. to 3 j.) painted over the 
s)K)ts night and morning helps the cui'e. In chronic lepra, with thickening 
of the patches, or whei*e there is much elevation of the disease — ex., the 
nummular variety, a more decided impression may be produced by rubbing 
in a solution with flannel, of equal parts of tar and spirits of wine, or equal 
parts of soft soap, tar, and methylated spiiit. 

When tliere is a tendency to " discharge," the nitrate of mercuiy oint- 
ment 3 ij'j with glycerine 3 ij., and camphor liniment 3 j., is useful. When 
cracking occurs, as in palmar and plantar lepra, a paste made of glycerine 
and borax is useful, or the cracks may be touched with nitric acid. Some- 
times the cuticle is so hard that it is necessary to poultice freely in order to 
soften up the hardened cuticular lamellne. Sometimes it is preferable to 
apply lotions to lepra; in that case the following may be useful: liquor 
carbonis detergeus ? ss. — 5 j'> glycerine ^ ss., water 3 viij. In very chronic 
cases, where the disease is limited to certain patches, it is advisable to use 
blistering, or iodide of mercury ointment (gr. x. — xv. ad ^j,) bo as to set up 
a revulsive action. The ill success which attends the treatment of lepra is 
generally due not to a want of remedies, but the mode of their application, 
and an inattention to individual peculiarities of diathesis, and of derangement 
in the assimilative and secreting organs. For other i*emedies, see Formula) 
Nob. 31, 68, 69, 86, 87; 112, 113, 124 et seq,, 140, 146-7-8-9. 
9 






Y^ ?^ r.ot/o be ra;wvxl/rom the 
-'-'•■:"•'' " "-1 l]i auy person or 



CHAPTER XIII. 

STRUMOUS DISEASES — SCROFULODERMA AND LUPUS. 

The stnimous habit of bodv often modifies the more common diseases of 
the skin. For instance, in lepra, the crusting is more distinct, and there 
is a tendency to the intermingling of pus corpuscles with the epithelial 
scales. So in ordinary eczema, in strumous subjects, there is more than 
ordinary infiltration of the skin; the cellular tissue beneath, and the seba- 
ceous glands are implicated ; there are locally more swelling and excoria- 
tion. Tliis is due to the strumous diathesis ; but strumous inflammation of 
the skin may exLst as the sole disease, and it is considered to include scrofu- 
loderma and lupus. In the former the general signs of struma, and the im- 
plication of the lymphatic glands and of bones are marked ; in the latter no 
marked evidence of stnuna exists, but it is regarded as a close ally o^ if 
not a j)ai*t of, struma. 

SCROFULODERMA 

Is characteiized by the appearance of indolent, dull red tubercular forma- 
tions, that tend to 8upi)urate, and are soon covered over with a darkish 
scab, from beneath which oozes an unhealthy pus. Ulceration to a greater 
or less degree takes place, and the healing is accompanied by distinct scar- 
ring. The whole disease is of the most chronic characlier ; one can scarcely 
mistake this strumous ulcei^ation for any other disease ; it may spread and 
cover a large extent of surface, and in this case the ulcerated surface is half 
covered by darkish iiTegular crustii, whilst the ulcers discharge a thin dis- 
agreeable dark pus, and gmnulations are flabby and pallid, bleeding freely 
on being touched : the edge of the ulcers is livid, and various attempts at 
repair are made. The mucous surfaces of the nose or eye may be inflamed 
and slightly ulcerated ; onychia may be present ; there are old scars of for- 
mer stnimous disease, and the whole aspect of the patient is a sufficient 
tell-tale of the disease. The treatment is generally most successful, viz., the 
adoption of better diet, the use of cod-liver oil, iodide of iron — certainly 
not arsenic — and locally an astringent ointment of tannin, or acetate of 
lead. 

. LUPUS 

Is characterized by the })resence of })atches of a dull red color, out of which 
arise tubercles, that ai-e small, circumscribed, vascular to a certain extent, 
and somewhat hardish : they tend to soften, sometim(»s to ulcerate, to crost 
over, and finally disap|>ear, leaving behind in process of cure indelible cica- 
trices. There is a low ^yp; of cell tissue dei>osited in the hkin in place of 



liar 
1th 



uomial m«t<?rjal- ' There are three forms of lupus. Tlie one iii which Uie 
deposit is slight and superficial, whilst there is no ulceratiou, Itijm* eri/the- 
malodea ; the necond, ia which the deposit ia greater, the tubercuhir fonna- 
tiobs niv distiDOt, and the sin-face is affected not in depth, but uvea, X. -non- 
The third vaiiety, X. aedeiit, is that in which ulcei-atioii occurs, 
eats deeply into the tifisuex. Sometimes hypertrophy occurs together 
ith cicatrisation, then we have Ivpva hypertrojihieua. Thesn foniiB ai-e 
dfigrees of one and the saiue thing. Tlie general health ix often apparently 
good, and tlie ditieuae ttes/at to be local : as Dr. Jones remarks, "the {lecu- 
tiar tissue change which enHiies upon tlie infiammation is the eeseutial thing," 
It has some unequivocal aJlinities with scrofulous cai'ies of bone, iicrofulous 
ditK>aBe of the skin, and tuberculous ulceration of the lungs, as before stated, 
and for these reasons I have classed lujms with strunioun affections. 
£rytiieiaatou« lupus, wliich may be aasociat^'d with other varieties, cou- 
of roundiah patches of a deep red color and shining aspect, without 
il)Ie elevation; indeed, the skin looks just as though it had wasted 
'.•Diiiewbat, or become dry and ahninkea from being " seared," though it iu 
roddeuud ; the diseased process creeps over the healthy skin (erythema 
centrifugum of Biott), add the surface of the disease gets covered over with 
thin adhercut scales, which on removal ex]i(iae a dry yet raw -looking surface 
aspect, and this may bleed. Ei-ythematouB lupus has been de- 
it« slightest form as an obstinate erythema, with slight loss of 
itaiice. The central i>art often thiiis without ulceration, or is covered 
by whitish scales; the disease now spreads from its boundary -edge, 
may then ejcbibit some slight tendency to form crusts. Its usual seat 
the face, cheek, nose, or even scalp ; general symptoms are absent, and so 
local [laiu. It may ulcerate. This ia noticed when the subjects attacked 
scrofulous, which is not always the case, at least to the appreciation of 
physician. The disease mostly attacks children, and especially those 
tlie lower ordere. There are then various degrees of tliia ei^thematous 
It may be repi-eaenled only by an erythema of dull red color and 
obstiiuicy, leaving behind a slight cicatrix. In otbcr cases there is 
more induration or elevation of the patch, and the loss of substance is sitme- 
wfaat greater ; the skin is thin, smooth, red, and shining ; lastly, this form 
May be somewhat uiodiiied by alight ci-ustijig, the scales being large and 
cicaliix deeper. 

t must uot be forgotten that patches of this diseas* may occur on the 

Ip, and on the fingers, hands, and toea, resembling chiibkins, but occurring 

lUt the summer, and &ccompaiiit!d by slight loss of subsiancu, thus 

from chilblains. Tlie sebaceous glands are sometimes found to be 

lly iavolve^l when the face is attacked, and pour out a somewhat more 

OldnMry amount of fatty matt'.-r. 

w <noa-Ari.leii)i has as its basis th« form first described ; but, in addi- 
de nodular elevations, wliich are softish, round, of a dull red, or 
ydlov color, often ((uasi-gclatiuous-looking, stud the part, and by 



132 STRUMOCTS DISEASES. 

their aggregation or even fusion form a patch of greater or less extent^ g^n^ 
rally of circular or seqientine form : these tubercles are covered by little 
scales, presently quasi-scabs, and little vessels are seen to run over and 
through the tubercles : this is very characteristic. The disease is seen in 
the face, especially about the nose, the lips, and chin. The central part of 
the patch may clear and cicatrize : this is the result of an absorptive pro- 
cess without true ulceration. The outer part is tubercular : there may be a 
semicircle of flattened tubercles at the edge, the central portion of the af- 
fected skin being tense and [>uckered. If the scales be removed from any 
portion, the part beneath is red, dry, shining, or even raw ; the upper layer 
next the cuticle presents an appearance which has been termed ** comified : ^ 
it is of transparent glue aspect. The papillary layer of the skin is mostly 
affected. The process of healing is always attended by more or less loss of 
substance and sensibility ; the cicatrix b below the level of the adjacent 
surface ; there may be some discharge of a thin nature. This form is not 
unusually associated with the erythematous variety, and may be coexistent 
with ulceration of the mucous surfaces near. The loss of substance is rather 
by intei*stitial absorption than ulceration, as before observed ; in some in- 
stances there is a general hyperti*ophy of the skin, with cicatrization. This 
is Biett's lupus with hypertrophy. 

Xfuptvs exedeiis, — Ulceration is marked in this species of lupus, which 
commences in the usual manner by the aggregation of tubercles : and then 
slight discharge, crusting, and subsequent ulceration set in. The tubercles 
in this variety are harder, and lack the transparency of those in L. non- 
exedens. The ulcei'ation varies in depth, being in some cases comparatively 
supei-ficial and extensive, or, on the other hand, deep and circumscribed. 

In the first case there is the usual attempt at repair, especially by scabbing ; 
but the ulceration is active and marked : hence, though the surface crusts 
over, and the loss of substance is decided : there is a thin ichor poured out 
by the diseased surface. In the second case the ulceration eats deeply into 
the tissues, the surface is " mammillated," red, quasi-gelatinous, ragged, 
covered by a whitish exudation, and the edges are thick and red. Cicatriza- 
tion may then, and generally does, take place to some extent. The nose, its 
mucous niembi-ane, bones, and, indeed, the whole organ, may be rapidly lost. 
In the cicatrix wliite bands of condensed tissue are seen running in all direc- 
tions. The disease is very chronic, and is accom[>anied by some local beat 
and tenderness, with pufHness of the surrounding tissues, and often pain of a 
gnawing charact<T. 

The peculiar destruction of tissue affects all the structures ; even the glands 
and hair-forming apparatus are destroyed. 

The disease may attack the vulva, and then occurs between the ages of 20 
and 50. 

Ktiology of Scrofulfx/erma and Lup^is, — The former occurs, according 
to Mr. Wilson, in the better classes of society, in 21, and lupus in 77 in- 
stances out of 5,000 consecutive cases. 



BTBUX008 D18KAB1M. lS3 

Ziuptu is a rarf! iliHease al^r 35, and not connuou aft«r 30 years of age. 
Devergie uotiuetl liiaL in 4d cases, 28 pOHsessed the lynipbatic and 1 2 a coni- 
biued lymphatic and noiiguiueoUH leupei-ameut. Iii many of the caites it 
occurs in phthisical Bubjects, It is more coiumou in the country than in 
town, and rather more in the fent.ile than the mala sex ; 25 ont of 47 caaes 
. were feualea (Dever^e) ; 40 out of 74 (Hutcliinsou). It is most common 

between lo and 3& ; Iti years was thu avera^ in Hutchiusou'a 74 cases, 
lu aeleotive seat is the face ; in 41 of 44 amen (Devcr^ie) this was the uuise; 
the nose was affected ia Iti cases ; the nose and otliiir parts of the face 
together, ill 2ti cases; thelijts. 4 times, etc. Lupus also alTects the Lauds, 

Rua, Ic^, etc. It is a disease of the poor rather than the rich. 
/Vo^notu.— The eryJJitsmatuus and uon-exedeua forms are remediable, but 
{uirc great attuution and cure. The other fomis tift«n lead to hideous 
Ibrmily, aud are intractable to a high degree. 
iMagnotia. — Lupus occurs in young people, runs an indolent course witU- 
t p4in, ia seated mostly on the fitce, possesses softisfa vattcular tuhei-cles, 
gbt scaly adherent crusts, and a gelatinous aspect ; th«re is no true ulwir- 
_v;on, the edg» is dull red, inflammatory ; there are attempts at I'epair in the 
sksiHt of cicHtricieB ; the glands are unatTected and the geiiei-al health is not 
cachectic, though not good : the patient may bo florid. 'Hie to-called serpi- 
us Itipiu is often syphilitic ulceration. In some cases of acne, the seb»- 
B glands may atrophy, and dej^ressed cicatrices ara luft; hut the seat of 
B iliiieaae, aud the absence of tubercles, suffit-e for the diugnusis. 
» Cancer affects especially the lower lip ; dues not occur before thirty ; is 
[\il ; ita ulcerpossesses everted, undeirmiued edges; its surface is fungoid^; 
:> iittempted cicatrices; tlie glands are diseased; there are no 
utx over the ulcer, but an uRunsive dischat^ ; the geiiei-al health is bad. 
tt/philU there is the earthy hue and the general cachesia dlHVrent from 
e clear skin of a lupus patient ; the tubercles are lai'ger, round, hard, and 
oopper-oolored ; they have no great tendency to desquamate or to ulcerate, 
«ud are found ou other jiarts of the body ; those of lupus are flatter, Hofler, 
uul covered by thin scales. Sypliilittc ulceration is foul, dirty, sloughy, aud 
iients a copper-colored areola ; crusts are greenish ; the edges are shurply 
V and everted ; in lupus with ulceration, the edge is dull red, intlamutatory, 
A non-everted ; the surfuce ia not foul. iJyphiJis has also a special history 
ri 8]>ecial concomitants. 

M( IHcsr. — Here the tubercule is large; the disease occura in old 
k; there is no tendency to healing; the course is very chronic; there is 

mJ*tUholof/y. — The essential feature of lupus is the presence in the sub- 

laoe of the cutis of new granulntion-tis«iie (as Virchow calls it), very soil, 

I more or less vascular, made Up of -an intercellular subntance, in which 

t imbedded round cells, with nuclei and nucleoli — a new form of connec- 

a form of cell pioliferatiou wliich may extend to any depth, re- 

I and invading the healthy structures, decaying and being absorbed. 




134 STRUMOUS DISEASES. 

Additional supplies of cell material are produced, and these go through the 
same changes as those which preceded. Some of the cells give rise to pus 
corpuscles when the disease is marked. The cells also undergo a fattj 
change. 

Treafment, — In the majority of cases the real treatment consists in the 
destruction of the lu|>oid tissue by caustics. But general remedies are 
neoileiU and these must first be noticed. Lupus patients, especially the 
young, ai-e often flabby, pale, ansemiated, and perhaps unable to get proper 
fooil. In a fair propoiiion they are phthisical, and this seems to indicate 
what turns out to be successful — the use of cod-liver oil and iron in full 
doses. But then there is tirst of all fre<piently a weak digestion present, 
and this needs to be remedied by mineral acids and bitters. If possible, 
change of air should W secured the patient, who should sleep in a lofty and 
well-ventilattnl roonu and take a large quantity of animal food, with more 
or less milk. A uum lerate amount of stimulants is also beneficial. In 
adults, general debility oftentimes allows a strumous or a phthisical ten- 
dency to have its way ; and in these cases we iind deficient assimilation 
exists. In such instances I liave seen the best results from large doses of 
nitric acid, with bitters and nux vomica- If there be loss of flesh and 
pallor, the syrup of ioilide of ir^^n or the sujierphosphate with cod-liver oil, 
dt^es giHMl. In florid subjtvts, the mineral acids act best; but these, to do 
any n»ai goi^l, must be given largely. Where the disease assumes the iion- 
extnlent form, aii«l the tuliercles ai-e well formed, the [mtient does not ex- 
hibit any debility, and has not been living on scanty diet, a short course of 
bioyanid'* of merourj- <gr. ^^ to -,', for a dose) i»ith bark is useful. Mr. 
WilstMi s)»eak^ well i»f the iinlide of ammonium in two or three-grain doses 
thnv times a day. In the ulcerating form. IXmovau's solution will be found 
useful in c^miiivtion with cihI- liver oil. IVmstitutional remedies may be 
aloiit* n'UiHi uinni if the lUsease is not extendiui;. Then as regards the local 
lit^tuvnt. The erythematous \-ariety of lupus wants ordinary stimulation, 
with suoh an ointment as the pyrvdignevms oil of junijvr ^two drachms to 
an ounct* of .^deps^, or one ^virt of oarlx»lio acid to twelve of glycerine — the 
former ust^i e\iry ni^ht, the latter omv a day, if it will be borne, and then 
the use of dilute citrine ointment : or, if then* be much heat, a ytLSie made 
of calamine jvwder, oxide of rino^ and glyctmne, and j^rhajis a little lead 
lotion. Tlir Aj'plioutiou v»f vx^lK^lion >»hen the disease is dlsapi^earing helps 
on the curt* \ery much. Howe\er, if the^* nu^asures do not «em to be 
suiWSNful, tlu* um* of |xuassa fnsa, with an e«)ual quantity of wat«*r. lirst to 
a limiuxl |v^rt of the «HlJ^\ ai.d p-adually, at intervals of several days, to 
other i^aits, will, ^ith j^*ueral nnutniieN* cun» liie dis«*aA*. The acid nitrate 
of mervMry is aluu^^t as usu^ful. But 1 think that ikhen the a|«|tlication of 
aiu>tiv's IS u^llo^itxi bv much dis<vmfort, heat* and sweliiui:* then the sdm- 
ulatin^; i»'.an is the U*st ; ami, indiv«i, if a )>atieui c^^mo* to 
irriiAt^Hi ar.d ]>ainful |^ioh of lupus< 1 «^xuhc for j^^ne time, 
lettd or opiate lotions^ or an oxide of sine |mct<>. In tbe non-exMlait fcnn 



STRUMOUS DISEASES. 135 

the potassa fusa, acid nitrate of mercury, Dupuytren's arsenical powder, 
iodide of starch paste (painless), the solid nitrate of silver stick, the actual 
cautery and the galvano-caustic, may be employed to destroy the tubercles. 
I prefer the acid nitrate of mercury, biniodide of mercury and glycerine 
(gr. X. to XX. to 3 j-)> or equal parts of potassa fusa and water. The rei)eti- 
tion of the caustic depends upon the quiescence of the diseased patch. 
The exclusion of the air by a layer of zinc ointment is advisable. In the 
exedent form the solid silver caustic is the best. It must be deliberately 
and freely applied, and chloroform should be given if necessary. The 
chloride of fcinc is prefen*ed by some. Others again commend nitric acid, 
mixed into a paste with sulphur, and laid on with a spatula. After caustic 
applications a poultice should be applied, and the surface dressed with a 
soothing ointment — elder-flower and liquid plumbi. 

In all cases where the disease has been arrested, and tends to heal, any 
mild si^mulant or astringent application may be used, or such as glyceral 
tannin, or nitrate of silver dissolved in nitrous ether (gr. xx. — xxx. to | j.). 
It must be remembered that local remedies act in efficiency in ])roportion 
to any improvement in the general health which we biing about by our in- 
ternal remedies. I think it important to avoid the use of local remedies 
when these produce persistent heat and swelling, for under such circum- 
stances the local applications only tend to the spread of the lupus, by inter- 
fering too much with the healthy action of the contiguous unaffected skin, 
and therefore the local reparative process. The disease can be made much 
worse by caustics. For other remedies, see Formulae 10, 12, 13, 16, 104, 
\2iet8eq., 139, kc. 



CHAPTER XIV. 



rANc:EROUS AFFECTIONS. 



Tl^KHKR this head I have to describe Epithelial cancer aud a disease allied to 
it called Roileiit ulcer. 

EPITHELIAL C'ANVER, OR EPITHELIOMA. 

This distMise atTocts the face, es}>ecLally the lower lip, the scrotum (coii8ti« 
tilting chimney -8 wei»i>er*rt c^uicer), the \-ul va, pi'epuce, the glands of the gioin, 
and i-aroly tlie anus. The earliest sign is a little hard lump under the skin, 
say the lip ; it is dattiah, hai-d, tsomewhat tender, and increases in size, so 
that the lip ^* )H)ut8 ; ** its surface may be somewhat (wde or dusky, and aoon 
b(H.vuu*s slightly moist ; at other times it is covered by a dr^'ish scab, or an 
attempt is made at *' (»apillatiou ; ** it may be also fissured; the tissues 
annind the swi'lling become luore or less indurated, though they du not ex- 
hibit any ovivlonoe of change u{H>n the surface ; ulceration now sets in in the 
slia|H' of a little cinitral exciu'iation or abiusion, aud this runs on to distinct 
los» of suWtance until an ulcer is proiluced, which has an eaten-out appear- 
aiuv : it is n»undisli, and iK^uudeil hy hard, indurated, sinuous edges, which 
ill an ailvtinotHl stag^' aiv evertt^il aud uudermineti, in consequence of the ex- 
t^'iisioii of nu»rbid aotii>n ; the l»ase of the ulcer is dirty or grayish, more or 
less |»apillattHl : it luay bt» rtHiilish aud inolineil to discharge a thin fluid, or 
Ik* disjH^s*»ii to scab o\er. In cancer of the ^•'i>ttnm the development of the 
|^piil:%' is [Hvuliariy niarkinl. llie dis<*asi* in this situation commences as a 
small pimple or mnlule, or warty excr\»soeurt\ which remains in a quiescent 
state >»iiliiHit undei-icoing inuoh cliange for sv>ine little time: it then becomes 
irritable, nnl. tender, exciuiatiHl. and gi\es exit to a slight moisture, per* 
haj^s slightly sv'ablH\l oxer: the nunsture inorvases s^mnnimes to such a 
d(^prtv that it is **a thin aoriinonious iclun*, which excoriates the summnd- 
iug skin.** Very olteii other lunlules a p} tear and coalesce with the primary 
oiit»c* : uhvration now s^^ts in in reality, the l\li^*s of the uKvr bec^^me everted, 
and thn»w out a luxuriant ^^wth with Mnniious haulut*?^ which discharges 
a xery tVvtid, initatiu^ ui.ttter. The pivj::x'>s of the disease* is acivu)Xinied 
b\ the de\eiopiueut of the {vipilu^*. m^ that by and by, ver\ early t^ometimes. 
the dis<^as«' Wk> like a •• fuuj^*ii> v-aulitlo^er exort^s^vnct' :" and this spiout- 
ing uUvration after a ^uile ev;eivds vkvpN into the tissue. 

thk s<v:ion, in »n e^rU >tag^\ the u;as> of a;; epithelial canosr looks of a 
graxiNh aN|Kv:, tillJ^■vi ^xx-asiouallv u;;h \ el low: a; the citvuiuteivaoe, the 
Uniiidarx of the di?«-as«« i> M^eV. decintM : :h. ;v ap'^y^&rv lo N? no stroMa, or 
at leti>t the >:rvniui i> foruud b\ the ti:i^ut« e: the (vftrt; KfiMath the papsl- 



EPITHELIAL CANCER. 137 

lary layer the surface is uniform, gray, shining, and close-textured ; gene- 
rally, the mass yields a slightly milky juice, and sometimes a semi-fluid 
cheesy material may be scraped from off it. In si>eaking of a diseased gland 
removed from beneath the jaw, which Mr. Paget examined, Mr. Hutchin- 
son observes, " Its cut surface presented a nearly uniform grayish substance 
with a diffused tinge of ochre-yellow here and there, with no ti-ace of granular 
or fibrous structure ; it was all compact, smooth, shining. It yielded on 
scraping a yellowish, putrid, gruel-like thick fluid." In the ulcers, the pa- 
pillary layer is made up especially of the cancerous cell elements, and the 
fibrous api>earance above described is visible beneath. 

Tlie microscopic features of epithelial cancer are briefly as follows, after 
Paget : — (a) Epithelial cancer-cells, which are nucleated, flattened, round, 
or ovalish, seldom regular, often angular in outline, and with processes: 
with granules clusteiing around the nucleus which exhibits occasionally 
nucleoli, but generally gi-anules ; the cells range in size from -^j^ to yuVir i^^ch, 
the nucleus on an avei-age is yjVir ^^^^ ^^ ^^® > (^0 ""clei about jj^ inch, 
free or imbedded in a homogeneous blastema; (c) brood or mother-cells, con- 
taining a varying number of nuclei in different degrees of development;, 
the brood-cell is said to pi'esent a concentric arrangement, this being brought 
about by the continuous enlargement of the nucleus until its outer wall 
comes into contact with that of the parent cell ; (d) what are called globes 
^pidermiques or laminated epithelial capsules, said to be diagnostic : they 
vary in size from t^tf *^ toO ^^^^ > ^^^y ^^'^ produced by the aggregation o£ 
successive layers of epithelial scales, curled one around the other like a ball; 
hence they look like fibrous tissue having a concentric arrangement i they 
contain granular matter, and nuclei are tolerably visible. Some say they 
are derived from the brood- cells, others by the aggregation of cells. All 
these elements are to be found in the juice expressed from epithelial 
cancers. 

^iiolclogy. of Epithelial Cancer. — In 90 per cent, the disease attacks 
men, and in about 90 per cent, of cases the lower lip ; the duiease is not 
common till after thirty, and its most usual time of occurrence i& about the- 
age of sixty. Of 222 cases collected by Paget and Hutchinson^ 207 were 
those of men, 25 women, and three of the latter are known to have been, 
smokers. The average duration of life in epithelial cancer ia somewhere 
about four years, when it attacks the cutaneous surface. It may originate- 
in a sebaceous gland about the nose or cheek. 

J%e Diagnosis, — Epithelial cancer is likely to be confounded, when seated' 
in the face, with lupus, syphilitic ulceration, rodent ulcer,, and unhealthy 
sores about the mouth. 

Its occurrence in late life, its seat on the lower lip^ the papillary ulcer,. 
with everted, hardened, undermined edges, and the implication of tho 
glands, are guides which prevent our being misled, as a general. rule,.aa 
regards the similarity to syphilis. In cancer^ the '^ sore is attended by more 
induration than are syphilitic sores ; it is usually single^ while the; latter 



185 OASOEBouB ATFson^re. 

are mostly tnulliplo ; it ca.uses eDlargemcnt of the glands, wbicli I«rtut7 
xyphilitic affectioua rarely do." lu »yphUis tli^ history of the disease, the 
absence of the [>eGnIiiir ecig<>-s of the caucei'ous xore, the early age uftentuiiea 
of the patient, signs of tiypliilis elsewhere, and the seat away fi-oni tlie lovrr 
lip, will gpnurally gnide correctly. Luput is a. disease of young life, and 
can Hcareely be mistaken for cancer. Jiodenl vlcer occurs between the 
ages of fifty anil sixty, but haa nuver yet been seen to attack the lower Up; 
it occurs somewhere about the tipper part of the fiice, near llie eye, it is bIov 
in progress, had no tendency to aSect the glanda, possesses no evertrd and 
no undermined edges ; its surface is not foul, papillary, but clean, aiid doM 
not give exit to any ichor. It contuiiia no tnie epithelial cancer eletneuta, 
but is BUuply fibrous degeneration. 

The Trtatmtnt of epithelial cancer is summed up in one word — reuova], 
and the euipluynieiit of a thoroughly tonic plan of general treatmcuL 
FormuliH 13, 13, Ac. 

RODENT i;H.'ER. 

• Rodent ulcer has been called cancerous ulcer of the face, cancroid a 
ulcus exedens, noli me taiigere. It has been confounded with cancer 1 
lupns ; and has been pretty generally regarded of late as 
fibroid ulcer, but there are tlioee who believe it to be cancel 
min Brodie, in refereiice to it, in bis " Lectures on Patholc^ and ii 
p. 333, says — " A man has a sms.ll tubercle upon the face covered ] 
smooth skin ; he may call it a wart, but it ia quite a different things 1 
cutting into it, you find it consiats of a brown solid substanue, Dot ■^ 
highly organised. A tumor of this kind may reraaui on the (aoe u 
for years, and then, when the patient gets old, it may begin to ulo 
The ulcer spreads slowly but constantly, and if it be left alone H | 
destroy the whole of the cheek, tke bones of the face, and ultitnately^V 
patient's life; but it may take some years to run this coi 
these tumors in the face and these ulcers are to be considered maliguant. 
NeTertbelesH, they are not like fungus hiematodes or cancer, and for this 
reason, that the disease is entirely local. It does not affect the lyniphftUe 
glands, nor do similar tumors appear on other parts of the body." Tho 
disease usually attacks some part near the eyelids; it is of alow progreMs; 
there is little pain. The disease has been described as commencing as a 
" piraple," " a blind boil," " a small hard pale tubercle," " a little long 
■ out ; " which tends to scab after a small central crack makes its app«araiic«. 
There is in fact a small pimple followed by a minute ulcer. Tlie disoBM 
extends gradually in all directions, but very slowly. When an ulc^r fomw, 
the edge ia indurated and raised, but uot undermined and cvprl«<l ; and 
there is no infiltration of the surrounding healthy structures. l*ke surface of 
the ulcer is dry, clean, glossy, and does not give exit to any foul secretion ; 
it is irregular in form, more or leas oval however. Mr. Paget «ys (t !■ ttot 



BOnENT UT^EK, 139 

r gnmulnted, aiiti tliei-e is no iijigrowth an in cHneoi'. If a BOrtion 
Q niiul^, il is firm, pals gray, and filiroUB. 

Mr. MiKii-e notices an important point in regai'd to the extension of dia- 
eBse. hi rodent ulcer it is eiiual in all directiona ; in epithelioma the growth 
tends downwards, and in two ways, partly, we are told, by tnuisfer of 
morbid materia! to the glnnda in the oTvjcal region, and partly by its morn 
rapid growth on the side iieaiext the central organs of tbe circtdation — that 
in, the line of transit to the heart, This Mr. Moore illustrates by the 
results of operationa where, in removing a tumor, he cnt throngli the 
icdematouB tissues on the distal side, and the apparently healthy structilrea 
on the proximal side ; and the disease returned in the latter and not in the 
former spot (suffering from impeded cirdtdation). This is of in]iortance in 
relation to operations. 

The disease dilfers fi'om the ordinary progreKS of cancer by its greater 
slowness, the little pain, little hemorrhage, the absence ul' any attempt at the 
formation of a fungoid growth, of fcetor, whilst the glands are not affected. 
The ulcer may cicatrize, but the ulceratidu ajjuin breaks out in the locality 
of fresji deposits. The advances of the (lojiosit and nioeration aiv unequal, 
hence the eaten-out or rodent appearance. The nlceration advances in deptli 
also, the cartilages renisting the most of ull the tissues. Tlie growth is al- 
ways in one mass, not in distinct centres. To Mr. Jonathan Hutchinson 
anil Mr. Moore we are specially indebted for a complete sum ninry of all that 
is known of the disease. The microscopic charactei-s are aa follows : — An 
excessivo growth of the tibro-cellular structure, well ileHned, hrin, and gray- 
ish, mingled with fatty tissue, free fat, epidermic stmctureit, exudation-cellfi, 
some of which are flattened and curled together somewhat similar to the 
globes ^pidemiiquea of e^iithelial cancer. Mr. Paget states that no true can- 
cerous elements ai-e present. Mr. Mooi-e Btat«a that he has found elements 
like thotte of epithelial cancer present. 

There is one peculiar difference in the behavior of the deposit tn scirrhns 
and rodent ulcer. That of tlie former possesses contractility by which the 
relation of the surronnding parts is altered. That of the latt«r does not, ho 
that the yet uudestroyed parts keep their position. This same wiiter re- 
mai'ks Ihat thongli there is no true iniplicstion of the lymphatic glands, they 
may occaiiionally acutely inflame or suppurate, but are never permanently 
indurated. 

Roilent ulcer then occurs on the face, has an induratefl edge, a tendency to 
spread without reRjiect to kind of tissue, is of slow pi-ogress, painless, is not 
rehited to any cachexia, never causes enlargement of glands, and microsco- 
pically ia seen to he " fibrous degeneration ; " it is allied to cancer, lieing 
probably ihe least ex])Fessed form of the cancerous cachexia. It Is most 
common between fifty and sixty, does not occur before thirty ; generally 
has ils seat about tbe eyelids of either sex equally, and never attacks the 
lower lip. 

J'athvlot/j/. — I have mentioned several important points in the attore de- 






m 



140 CAJfCKROrS AFFECTIONS. 

scription bearing upon the nature of the disease, especudiv as regards its 
allitinoe with cancer. Mr. Moore, to whom I refer so mudu has written an 
admiranle book lately on the subject, and he inclines to the belief that ro- 
dent ulcer is not a fibrous degeneration, but a form of epithelial canoerf be- 
liexina; that as com^iared toeethtrr, rodent ulcer is composed ^ of a more fee- 
blv vital material.** and therefore ^^ the occasions are rare in whidi it imi- 
tates the cancerous character, bv pai»»ing on to a subordinate hrmphatic 
giand.'* Indications are found, he holds, in its microscopic historr of the 
presence of cancerous iepitL»'Lioma) elements. This is. however, not the' 
experi*^nce of othrr ob6*frv«>r& up to the present tinke. The comparatiTe fis- 
oility of extir{«tion is not regarded as an e&s«rntia] difference between rodent 
di^ea^e and cancer. The infiltration, too. of p«rts aroimd the seat, or reco^ 
uizable seat, of disease, is looktrd u{mju as a matter of degree ; and so is the 
usual e3iLem[>ciou of ^!ands. u|K>n which tho6«> who denv the cancenms nature 
of rodent uicer Ut the greatest sti^^ss^ for we are told that ** to look upon 
the power of infevting glazids as rs«jential tc^ cancer, wonid be to confoond it 
with enchondrv>ma or tubercle^ which do the same, or even with skin tattoo- 
ed with gunj'owder.'' Mr. Moore su^:ge*red an explanation for the non- 
infeetiou K^^i the glands in Dxi«*nt disease — that it b to W fbond in the nature 
of the dLsea»e\l material itselfl which is inca|iable oi growing when tran^lant- 
ed. axid the atceu^iatioa :>f the natural textures : so that their abiiorbent ac^ 
tivity is lessened, or tLere remaius Iittl«* material ready to pass to the glanda. 

*" The rvKient v*auvvr is an ex*^iiisite insrance of a local ailment, being 
alm<vt uuiuterruptedly vvsitiuuous in its gr^-^wih. from the sotxtarr pimple 
in wLi^-h it originates, over an area of half ihe l^'e. At the same time* how- 
ever, that it oas every l-.val qualitv of caC'.vr. it is $o meagre a growth that 
is has uo suijerduous uiaterial fL*r v.'Lrvuiarioii in the bi>>jd to -tiitant frrfci^ 
and veni- little for the Ivuiphativis and the textures nearest to it." 

However, as I said before, lu^v^t wrk^us regard the disease as a fibin— 
degeLHftauoi:. 

/'i»*'/''KVf4A — "• Au ukvr with bard siuuoas ixt^Ss. siruatcii on some part of 
the ui»i«er t%'>thinis o! tiie ftkvv. of several or Tvrfaars umnr vears* duration, 
jkhuv^ii'C i««av.le«!W» Aud /v-vu rriv.g in a inuidie-a^^M or -flderiy j^rson of fidr 
health and without cuL^u-^-d ^tau^is. Such a S4.'re *j<^ almost certain to be of 
:Qe n.Meut tvT.e.** < Hu:v*Qitts«.«ti. > U uia^ be vVll.^.*naded with '■*/«•*, 
ijurio > fiHt . -« V ' '• • • ' v". ^» ' ^ » '. '. : I » « s ^'vv u :> Vc h." i e : lie Jk;e o f thirtr. ne ver 
mi«.id:e lite, axit.t alw*t\> Tt'ruU to lictil. 

*' Lf f^M^ Tie»^i : . <* ,ts A VI • •. *, 'a « >* ^ •. '. I S* rcu Ii*us -f le > a t ii.« a ..^ f the skin ; rodent 
cancer has a ri uj. u:ivvii.':»i hvmuV i^i xi. l*.t >rv*is there mar be more 
'ihan one tubiTvU*. .i:ui '.-lo '.•••.cr^eiivi^ >k'jj riKo '.v bt-althy* or pink, or 
sea! w or *.evi»"»iiatouM ; 'hT* pimpii* -'f r^^kHj! .-tirKvr is >*.»iicarY. The sor- 

« L m 

fjATe •.»! lu p u s d rxc N«.-H;t>H -. • r 5 H -^ • I X S- t't »i>" i . lu\'«ftkN ; •. ■ u* »^.'de a t cancer exco- 
naSes«, .uid iheu mtsIom. m bto\\ix. ls.*i;i uiVvtH'.e . '.iio '.u,vus aC one or at 
-^^T*.' -.'f it'^ "ilvivtvjs, '. Ito ••^len^ ^;tvvi "'m I'nx' 'iiore deepening of Its 
•.-^u'ral scabbe\i e\c\*rtatK><i. l.u(>u.x *ii<«,% cicairuv and ^-vikse at any time ; 



RODENT ULCER, 141 

rodent cancer proceeds with at most but a temi)orary and partial healing 
near its edge. When both are far advanced, . the lupus has a superficial 
appearance, though it have destroyed the whole nose ; rodent is precipitous 
and excavated. Lupus possesses, rodent cancer is without any, contractility. 
The margin of lupus, though thickened, is low, and bevelled both outwards 
by cedema and inwards towards the shallow ulceration ; that of rodent can- 
cer is firm, and is commonly, in both directions, abrupt. The ulceration of 
lupus is smooth, and may be multiple, being divided by scars ; that of rodent 
is single and rugged. In the vicinity of lupus there are sepai*ate, rather 
soft tubercles, and an area of pink scaly integument ; around the rodent 
disease the skin is healthy ; and if a separate nodule do exist, it is compact, 
firm, and in great part subcutaneous. Lupus is not invariably limited to 
the face, but may at the same time ai)pear on the hands or elsewhere ; rodent 
cancer is eminently local and centrifugal.'' (Moore.) 

Cancer occurs generally about the lower lip, rodent ulcer never ; in can- 
cer the glands are affected, the general health is bad, the ulcer is moist and 
gives out an ichor, is warty more or less, its edges are everted and under- 
mined, and the parts around are infiltrated by cancerous material, and it is 
of more rapid progress. Syphilitic ulceration is more acute, there is no 
indurated solid edge, there is pus formation, the' ulcer occurs often at an 
early age, the origin is not from a " pimple," and the concomitants of syphilis 
exist elsewhere about the body. 

Treatment, — The treatment is simple and satisfactory. Experience 
teaches us that extirpation by the knife, safe in the earliest stages, is the 
only successful m<)de of treatment, and it is effectual. Mr. Moore has lately 
shown that even in advanced and extensive cases the free use of caustics 
after as much of the disease as possible has been removed, is attended appa- 
rently with comple success. ^ But I must refer to his work on rodent cancer 
for fuller surgical details. When once the diagnosis is made, the line of 
procedure is easy, and it is extirpation. General remedies are of no avail. 



CHAPTER XV. 

SYPHILODEKMATA, OR SYPHILITIC ERUPTIONS. 

The remarks under this head will apply mainly to the effects of 8y[>luli8 
upon the skin. Tlie result of the introduction of the syphilitic i)oison into 
the system Ls to derange more or less the whole of tlie nutritive pixxresses of 
the body ; as a consecjuence, we have a pyi*exial condition similar to that seen 
in everj' zymotic disease, only more deliberate and chronic, and which has 
been temied " syphilitic fever." In some cases the infection of the system 
is so insidious that this febrile state is not marked or scai'cely at all recog- 
nizable. '^ The blood is charged with a poisopous piinciple, and a&Il the 
organs and structures supplied with that blood suffer to a greater or less 
extent. The brain evinces its suffering by mental dejection ; the nerves by 
a general feeling of prostration and debility .... there is often neuralgia 
(nocturnal) .... the i)\ilse is quickened .... the tongue coated, white, 
broad, and indented by the teeth. Tlie fauces are more or less congested, 
the tonsils and soft palate being frequently swollen ; there is irritation of 
the lar\'nx, producing a mucous cough and often nausea .... the conjunc- 
tiva is congested and muddy, and the whole skin remarkable for its yellow- 
ish and dirty a]>pearance, looking as if saturated with impure and discolor- 
ed humors." (Wilson.) The muddijiess of the complexion is veiy charao- 
teristic. Dr. Bro<lrick has called attention to what he believes a diagnostic 
sign of the (existence of an acquired syphilitic taint — viz., aub-stemal tender- 
ne«H / it was noticed by Ricord. Various diseased states of internal organs, 
of the special senses, and fibro-cellular stnictui'es also i*esult from the poison 
of syphilis, especially in liereditAry instances. Syphilodermata exhibit tJie 
same elementary lesions as ordinary eruptions ; they ai*e erythematous, pa- 
pulous, squamous more especially, but also bullous, tuberculous, vesicular, 
pustular, etc. But th<»y possess certain modifications of features as to 
color, shaj>e, etc., to In? innnediately noticed. Syphilitic taint giving rise to 
eruptions may be heivditary or acquired. 

Ilerediiavy nyphiliH is j»racticully synonymous with congenital or infantile 
syphilis. The child, how<»ver, may be tninted through the medium of the 
milk of a syphilitic nurse. Congtniital syphilis may be derived (a) from the 
mother contaminated befoit* or after conception ; (6) from the faUier (the 
mother being h(*aUhy) ; (o) when the parents art> both syphilized, in double 
degree. It is uncommon lx»foix* th(; end of the second or beginning of the 
third week, rare after the sixth month; the usual |)eriod of occurrence is 
when the chihi is about three weeks or a month old. No one can mistake 
the tainted infant. The genenil aspect is more or less marasmic, shrivelled 



SYPHILITIO ERUPTIONS. 143 

^' old man '^ like. The skiu is dirty, muddy, it has lost its elasticity, and 
hangs in loose folds ; it is dry, often exfoliating, and erythematous about 
the buttocks.- The cry of the child is harsh, ci*acked (characteristic), and 
'^ the snuffles ; *' the presence of mucous tubercles about tlie anus and the 
mouth ; the fissures at the angles of the mouth ; ulcerations of mucous sur- 
faces ; the high arched {lalate ; the inflammation of the thymus gland ; va- 
rious eruptions over the body, especially about the feet and hands (perhaps 
bullous) ; a subacute onychia possibly present ; and a family history of 
syphilis — are diagnostic. 

With regard, however, to the eruption, it is generally in the form of a dull 
red erythema of the hands, feet, and peri-anal region, with more or less tu- 
bercular formations. 

Acquired Syphilis. — An adult may exhibit hereditary syphilis, pur et 
simple. Acquired syphilis is more common, and has three groups- of 'symp- 
toms. 

I*rimaryy which is simply chancre^ with which I have here nothing to do ; 
secondary and tertiary symptoms, made up of eruptions, diseases of the bony 
parts, and ulcerations, which follow as the consequence of the introduction 
of poison into the system, mostly by way of primary disease. The secon- 
dary forms of eruption are— roseola and maculae, lichen, psoriasis, tubercula, 
pu8t\d» (ecthyma, acne), rupia, onychia, and alopecia ; accompanying these, 
are enlargement of the cervical and inguinal glands, mucous tubercles, noc- 
turnal rheumatism, loss of hair, and anaemia, more or less marked. Tlie 
teiiiiary are — erythema and psoriasis of the hands and feet, the ulcerating 
tubercular forms, mucous tubercles, and syphilitic ulcers. Tlicse latter are 
generally accompanied by cachexia, nodes, periostitis, laryngitis, and deeply 
seated mischief — ex., in internal organs. 

The syphilodermata have certain peculiarities : — 

1. There is a history of syphilitic inocvlation^ which tells its tale by the nu- 
merous symptoms (due to the circulation of the poison), noticed at the open- 
ing of this chapter ; and, in addition by the presence of cicatrices, indura- 
tions, scars, and stains about the penis and groin. 

2. Tlieir color, — It is described as copper-colored ; in reality " a reddish 
yellow brown " (Wilson). It is dull red at first, and becomes coppery after 
a while, and as the eruptions vanish a dull red or yellowish dirty stain re- 
mains for a varyiug length of time. In the early stages of disease the tint 
may be violet, but this soon becomes re]>laced by the coppery hue It is 
well marked in the tubercular forms, and at the circumference of lilcei-s and 
pustxdes. 

3. Their form, which is peculiarly circular. This feature is not perhaps 
of much moment, per se, but in conjunction with other points is of some aid 
in a diagnostic sense. It may be destroyed or prevented by the confluence of 
other patches, but even then the typical for*n can be recognized in the 
component parts of the patch of disease. During the progress of syph- 
ilis there ib a tendency on the part of the eruptions to assume the aspect 



144 SYPHILITIC KRUPnONS. 

of several forms at different times — a papule becoming a pustule, and 
so on. 

Syphilitic scaly eruptions ai'e composed usually of small circular spots. 
Scales or squamw are thin, oftentimes very fine, gray, and few in number ; 
fewer anil lighter than in non-syphilitic cases. 

Cruses are thick, greenish, or ))lack, and firmly adherent. Vesicles are 
liattish and do not remlily niptui-e. Ulceration is a common feature ; the 
ulcerated surface is aiAy gray, covered with a pultaceous substance, and 
boundr^d by 8liarj)ly cut edges. Cicatrices are whitish and reticulated, or 
dull and bro^niish, leaving in their place on disappearance a yellowisli stain. 
Fissuriiig is marked in the squamous forms. The horse-shoe form of pustu- 
lation or ulcer is very characteristic. The serpiginous is suspicious. 

4. The Absence of Pain or Itching, — With the exception of mucous tu- 
bercles and some forms (moist) of infantile syphilis, syphilodermata are said 
to be generaUy unaccompanie<l by heat or pruritus during their existence. 
I cannot subscribe to this. In syphilitic lichen, even erythema (roseola), 
the pniritus may be distressing. In the tubercular forms, just prior to ul- 
ceration, the pix)cess of softening renders ' the tubercles sometimes painful 
and tender. 

5. Polymorphism, — Tliis is very characteristic of syphilitic disease. Sev- 
eral diffei-ent kinds of eruptions may co-exist, and this is a rule of general 
applicability. It is no unusual thing to see papules, pustules, and squam» 
coexistent in the same syphilitic subject, and, as before remarked, one 
form mav assume the characters of another. 

I shall give the salient features of the various syphilitic eruptions. 

PlCiMENTAKY STAINS, OR MACULAE SYPHILITIC^ 

Are generally a i-emnant of other fonns of syphilis, mostly of roseola. 
They gt»nerally commence by slight pyrexia, |)ain in the limbs, anorexia, 
headache, and malaise, followed by the development of little roseolous spots, 
which siH»n fade, take a dirty -brown as|>ect, and subsequently a rather lighter 
hue. These niacuhe ai-e neither elevateil, itchy, nor hot; they are circular, 
in size ranging between that of a fourjienny-piece and that of a florin, scat- 
tere<l over a ]>retty largt» area, usually isolated, but occasionally confluent, 
forming s<»metinies lutnds (annulose) ; they do not disap|iear on pressure, 
ami their es]ieoial st»ats aiv the neck, the breast, the face, especially the fore- 
head, and the arms. In children the maculation is so complete that the 
whole surfaiv ha« an earthy hH»k. In ac<iuired syphilis, in adults, there ia 
oftentimes a signifiount staining, jmi*tii*ularly well seen about the forehead. 
Macula* syphilitica* an* unattendtnl by pruritus or desquamation, and some- 
tinu»K iHvur in conjunction with other fonns of eruption. It has been said 
that they cimstitute a primary form of disi^ase, but it is the nde that they 
ci>nunenct» as roseolous K}H>t8, though the red blush may be very ephemeral 
and esca]>e detection, lliey can only In* confounded with pityriasis, but in the 
latter there is des(|uaiuation, itching, elevation, and absence of the copperiA 



PAPULAB PYPHILODEEM. 145 

hue, and a want of circular form. Chloasma is attended with itching ; the 
color is fawn, without any shade of copper tint ; the surface is elevated, 
rough, and desquamative, and the microscoi>e detects parasitic elements ; 
chloasma, too, is peculiar in its seat. Syphilis never produces such staining 
as chloasma. 

EXANTHEMATOUS SYPHILIDE, OR SYPHILITIC ROSEOLA. 

This is one of the earliest secondary symptoms, occurring generally be- 
tween the sixth and ninth week after the reception of the primaiy mischief. 
It is preceded by pyrexia of mild character, prostration, and very frequently 
more or less irritation of the mucous surfaces — e. g,^ redness of the fauces, 
sore throat, etc. The eruption commences as little I'ound spots of a pale- 
red color, with very well-defined edges, which may appear very suddenly, 
often in the course of a single night, acquiring in a little while a perfectly 
pale-rose tint ; the spots are unattended by itching, and observed usually 
most perfectly and abundantly on those pai*ts which are well covered and 
kept warm by clothing, especially flannel ; hence particularly on the trunk. 
The little patches may be slightly elevated, isolated, and round ; they fade, but 
do not disappear on pressure. Sometimes they are scattered pretty freely 
over the trunk, the upper part of the chest (esj)ecially the lateral parts), and 
on the back. When the rash fades, it always leaves behind a branny-like 
or more deeply colored stain ; the epidermis desquamates in largish but thin 
scales. This latter condition becomes more decided in a few more days. What 
strikes one is this : that there is evidently a large scattered amoimt of erup- 
tion without apparent cause, without local irritation, and only the slightest 
febrile disturbance, the eruption leaving behind a dirty staining. The cop- 
pery hue is evolved out of a roseola, which is somewhat dusky on its first 
a|>pearance. In ordinary roseola the tint is vivid, and quickly disappears. 
The stains left by syphilitic roseola, when the congestion has disapi)eai'ed, 
constitute the so-called Macidce /St/philituxe, before noticed. In syphilitic 
roseola there is usually not only redness of the fauces and tonsils, but ulce- 
ration. 

PAPULAR SYPHILODERM 

Assumes the form of lichen, and all authors agree in describing two forms, 
the acute and the chronic. 

The acute consists in the development of small, hard, pointed papules, 
which are packed closely together, each being attended at the outset with a 
red areola, affected by pressure. The papules are seated upon the face 
especially, and also the trunk (on both aspects), the neck, and less frequently 
the limbs ; they become covered over with fine grayish scales, and occasion- 
ally become pustular or ulcerate. The eruption is scarcely successive, for it 
arrives at its full extent within a couple of days or so. Slight febrile dis- 
turbance precedes the development of this state. When the acute stage is 
paased, the disease appears to be constituted by little dark points or papules 
10 



146 STPHTLmC EBrPTIOXS. 

seated upon a somewhat dull-red base ; in a few more days this dark hoe is 
rtrplaced by a well-marked copper color, and more or less desquamation. The 
disease lasts a month or so, leares behind more or less staining, and little 
cicatrices or pits, which Jire very characteristic. This form of syphiloderma 
then commences with congestion and subsequent deposition in the form of 
fmpular elevations ; the fieculiar coppeiy tint is masked at the outset bv the 
congestive redness, and oidy shows out markedly when the latter disappears. 

Tlie chronic form of lichen {possesses a slower and more indolent coune 
simi>ly. The papules are larger, numerous, flat and broad, copper-colored, 
without distinct areola;, local itching, pain, or heat ; they are seated on the 
outer sides of the limbs, the forehead, the trunk, and even the scalp. The 
papulefl are successive in mode of a|>i>earance, and on their subsidence leave 
behind coppery stains. The papules often become pustular. 

The IMar^nosiM of syphilitic lichen is generally easily made. A prior his- 
tory of syphilitic inoculation ; the seat of the eruption on the &ce especially, 
its general distribution, coppery hue, and tendency to become tubercular ; 
the absence of pruritus and imin ; the general cachexia of the patient, and 
the evidence of concomitants — e. ^., mucous tubercles, roseola, nodes, sore 
throat, etc., suffice. 

VESICULAR 8YPIULODERX 

Is very rare. The vesicles are grouped together, and possen a copper- 
colored base ; the disease is indolent, and usually possesses a very well-de- 
fined edge : there is an entire absence of the ordinary local symptoms of ve- 
sicular disease — viz., itching and heat ; the vesicles too are often abortive, 
and may (quickly dry up, thin scales take their place, but a dark stain 
remains. Slight pyrexia is not an unfrequent antecedent, and significant 
concomitants are generally present. Hardy describes three aspects : they 
ai-e, eczematoiu) syphilide, vaiioliform syphilide, and herpetiform syphilide. 
The vesicular syphiloderma, or syphilide, occurs mostly in the form of herpes, 
or a modification of the bullous form of disease, in which the vesicles are 
varicellous or deprenseil more or less in their centre (varioliform). 

When there is slight vesiculation over a largish area, we have the eesema- 
to\i» form ; if much crusting or pustulation, it is called impetigin€M9 / in other 
cases there are largish distinct vesicles seated upon a dull-red base; the 
vesicles do not easily rupture, but desiccate, and are replaced by dark-colored 
scaly scabs. Tliis is the herpetiform syphilide of books. In all cmaes a coi>- 
I>er-coloreil stain is left behind. This herpetic syphilide is noticed on the 
face, limbs, trunk, and i>enis, often associated with other syphilodermata, 
and generally within six months or so after primary disease. In the varioli- 
form variety, the vesicles are about the size of lentil-seeds, disseminated and 
intermingled with little bull», which are pointed, and now and then umbii* 
icated. They iK>ssess the characteristic areola, cnist over in a short time, 
bemiath which a copjier stain exists. The heqietiform sypilide may occur 
in the form of a ring with a clear centre. 



BULLOUS BTPHILODBSIL 147 

The Dtagnaaia is based upon the absence of fever, the persistent state of 
the Tesicles, the coppery tint, the brown or dark color of the crusts, the 
staining, the history of the patient, and concomitant conditions. 

BULLOUS SYPHILODERM. 

Under this head are ranked rupia and pemphigus. Dr. M'Call AndcFSon 
informs me that he has seen a second case of syphilitic pemphigus in the 
adult. 

Rupia is known by tbe development of small flattish bullta (surrounded 
by a faintish areola, perhaps by none at all), few in number, containing at 
the very outset transparent serosity, but very speedily a mixture of blood 
and pus, giving place by desiccation to thick scabs, beneath which is more 
or less unhealthy ulceration, yielding a nasty, dii'ty, foetid discharge. The 
crusts are diagnostic ; they ai*e dark, stratified in such a way as to be coni- 
cal, like an oyster-shell. There are three forms : R, nmplex, JR. eschwrotica, 
R. pronUneiu. 

Erasmus Wilson considers the first and last to be syphilitic, and B. escha- 
rotica to be the same as pemphigus gangr»nosum, or cachecticum. K. sim- 
plex is very like pemphigus ; the contents, however, are thick, bloody, offen- 
sive ; and the scab is dark, thicker in the middle somewhat, and therefore 
slightly conical : the scabs are often successive ; in process of cure, it leaves 
a red stain behind ; it affects especially the legs, loins, and thighs, never the 
fiace or head. E. escharotica, or pemphigus cachecticum, has been described. 
The general symptoms are those of irritation and deficient nutrition, with 
more or less hectic. The disease commences by bullsB, which fill with sanies, 
and break forth into unhealthy ulcera : it has no thick crusts, and hence is 
really pemphigus. It attacks the lower limbs, the trunk, the neck, and 
scrotum. 

R. prominens attacks the upper and lower limbs, and the trunk'; the buUn 
are few but large ; the secretion is free and thick : therefore the crusts are 
large and particularly well-marked, conical, and prominent : hence the name. 
There is usually an areola around the bleb ; the scabs augment by accretion, 
and cover over deep ulcerations. The scabs are dirty and blackisli ; they 
are sometimes almost an inch in height in the middle or a|)ex of the cone. 

JEtiology. — The cachexia of syphilis. 

IHagmms, — ^In rupia the bull» are small and fiat; their contents are 
bloody and thick, and the scabs are dai*k, thick, and conical. In pemphigus 
the bulls are larger and full ; the contents are clear, not dark ; ulceration 
is slight, and the scabs are thin. In ecthyma there are pustules ; the areola 
is well marked, the base is indurated, the scabs are adherent ; there are no 
conical crusts, and the ulceration is not so deep. 

There is little difference apparently between pemphigus and loipia, except 
in the d^^ree of crusting that occurs ; rupia differing from })emphigus in the 
fact that the ulcerated base of the b\dl» gives out a peculiar secretion which 
dries into thick, dark-colored, and more or less conical crusts. 



14S BTPHmno EHUpnoire. 

Pemphigus ill the very young may or may not be syjiliilitic. It may be 
ppidemic, attacking robuBt healthy children, running the counie of oriUniuy 
pemphigus, and wanting the concomitances of ayphilia; in this aajiect it is 
met with among the infants of lying-in hoapitala, and appears to be much of 
th« nature of, and produced by the same causes as, erysipelas, Non-ftyiih- 
ilitic and non-epidemic pemphigus is not usually seen iu diiklren before tha 
seventh or eighth month of age ; the contents of the bullie (which are dis- 
crete in this species) are serous, and there is little tendency to ulcuratioQ. 

iSyphHitu; Pemphigus is now regarded as a positive existpjice. It occura 
in those children in whom we can trace an hereditury tendency to rcphilis, ia 
those who exhibit signs of constitutional tainting (earthy hue of skin, Miuf- 
fles, wasting, mucons tubercles, lepra, etc.) ; about the hands and feet espe- 
cially ; the bulls) are abundant, their contents puriform, und they poBseas 
& great tendency to ulcerate more or less deeply, the ulcers Laving a cop- 
per-colored areola, and a nasty, dirty, foul surface, with thinly cut edges. 
It is sometimes congenital, and is seen moat frequently before the end of the 
first fortnight of existence. Sometimes the bulla may be not well murked, 
and Boabbing may be extensive in degree, the disease ekhibiting a close rela- 
tion to rupia; indeed herein we see the link as it were between rupia and 
pemphigus. The ulcerative tendency displayed by syphilitic pempbigua is 
no doubt dependent upon the cachectic state of nutntiou brought about by 
the syphilitic poison. 

PUSTtTLAR SVPRILODERM. 

There ftTo three forms : (n) pustulating lichen or pustulating tithercules ; 
(i) Uiftt in which the pustules areprimary, small, and resemblitig acne, often 
called tubercular syiihilis — the By])hilide puatuleuBO aciiiforme of Hardy; 
[c) in which the pustules are larger, and assunie the aspect of ecthvina 
(jAlyeacioiis). Rupia was described under tlie head of bullous eyjthiUde ; 
it is not truly pustular. 

1, TTin Jirtt, or pit glular lichen of Wilson, is seen about the forehead and 
face, and on (he tnmk ; the pustules are successive, numerous, isolatml, Diid 
scattered ; soon acquire a coppery hue, and are indolent. Sometimes they 
are flattened, at other times conical, the points or summits being puruteot; 
a thick greenish crust forms beneath which is an ulcer, depressed in its cen- 
tre, and leaving behind a more or less marked cicatrix and cop])er-aoIored 
stain ; this is often associated with other forms of syphiloderma, and pre- 
cederl by febrile disturbance. It often remains in one condition for weeks, 
being remarkably indolent, the crusts adliering very closely and perns- 
teutly. 

2. Tlie Meond is the aenifm-m variety. In this disease, the pnstulee are 
the size of small seeds, and the seat of disease ia seen to be the sebaoeous 
follicles. Tlie pustules develop and change slowly; (iere is a coppery 
base, and dark or dull yellowish adherent crusts form, and thei-e is pittii^ 
left behind after cure. Other forms of syphilis are mostly praa^^^^^^^^ 



^P PUBTULAR BTFHILODEBH. 149 ' 

^th. Tftuturri believes there are two forma — {o) tlie glaudular; (J) tlie fol- 

a. la glandular syphilitic acne, the parts nttacketl are the epitlielium, I 
the proper wall of the sebaceous gluud, auil the nelghboriug conuective tis- i 
sue. It is distinct from imjietigo iii the fact that the epithelial lajer alone 
in involved in that disease, whilst yellow cniats form which contain a Urge 
amount of nucleated epithelium, like that which is normally present in < 
glanils, granular epitheliikl cells, jius-oells, and fatty matt«r. These elements I 
are in small quantity in syphilitic acne, hut the deeper parts are chiefly in- ' 
volved. Simple impetigo is catarrhal, syphilitic acne parenchymatous. 

Tlie iliagnoiitie cliaraoterg of this glandular acne, according to Tnnturri, 
ore in the earliest stages the occurrence of spots on the tnink nnd iimbs, the 
acuminated pustules, their hai'd base, ceiitra! suppuration, and the tendency 
to desiccation. lo the suppurative stage, the hard base, central depi-ession, 
the liard dry adherent crust of small size. In the latest stage the marked | 
indurations, with central suppuration and desquamation ut the circuiiifc- t 
rence ; and lastly, the superficial cicatrices, the presence of pigment and ' 
fine scales. With regai-d to chronic syphilitic acne, the parts aifected are J 
the face, neck, trunk, and limlis; the pustules have slightly projecting basns, 
they are slowly developed, and suppurate only at tlicir centre. | 

Follicular acne Dr. Tanturri believes to be catarrhal ; the part affected 
lying just above the openings of tie sebaceous glands, the epidermic 
I— not the 'JernUe — Uiei-efore it is not parenchymatous ; it may occur in 
syphilis, of which it is on early symptom ; its pi-ogress is slow, and it is of 
long duration. It is marked by a large development of epidermic cells, and 
may leave behind a sort of ichthyosis, with desquamation. It appears on ' 
any part of the body save the face, and in all cases there are pustules with a J 
projectiug base, a rose-colored areola, a yellowish centre, traversed by a hair. 1 

S. The third or ecthymatous form (ectLyma syphiliticum) is .seen about 
the trunk, but especially the limbs, the lower more than the upper, and oc-- 
casionally the head. The pustules are phlyzacious, scattered, with a coppery 
base, and indolent, flattened, scabbed over with dirty brown or blackish 
scabs, covering ulcers with indurated and dark edges, which on healing leave 
behind cicatrices and charade listic stains. It may commence as a quaai- 
vesicular (bullous) disease, ea*;h vesicle having a re<i base, quickly enlarging, 
pustulating, and breaking out into obstinate ulcers ; the crusts are [peculiarly 
thick, and veiy adherent. 

The relation of ecthynui, pemphigus, and nipia, of syphilitic origin, is veiy i 
close indeed. 1 

Th« Diat/noiw.—Wliea Uchen, or even tubercular syphilis, pustulates and 
assumes the aspect of ecthyma, no difficidty can arise in diagnosis. Syphi- 
litic ecthyma is distinguished from aimple ecUiyma by the special history of 
the case, the concomitance of other syphilitic lesioua, the coppeiy hue, the 
thick black crusts, the foul ulcers, the depressed scar, and the absence of a 
syphilitic fi-om simple acne, by the ulceration at the apices of 



^^^ey a 



150 ffTTini.iTic ERtrpnoNS. 

the piistided, an<1 the cicatrices left on healing, the absence of piun, tiie in- 
dolent, non-inttanim[itoi7 aspect, tlie antecedent tind concomitaut hi&toriea. 

Sijl'AUOUX STPUILODElUt 

Conunences after puberty, as deacrihed by Biett : the prewnce of a littJe 
white rim around the bsfie of each patch in peculiar; it does not attack the 
elbows and knees by special predilection. A special form, fc/rro nyphUitiea 
nitfrifans, has been described ; in it the color of the patch is black, espociaJljr 
iu its middle, the form circular, the margin more rained than the centre, the 
sijuatnn very fine and dry, the sui-faco beneath shining, and therv is a gen- 
eral earihinesR of the surface ; the disease sometimes has the a|i]>eamnc« of 
darkish livid Htaius. In other instances, the squamous syphiloderma asanmcs 
tlie aspect of wlmt is generally regarded as psoriasis, particularly tlie ramty 
guttata. There is a disposition to a circular form; solitary isolated apots 
are seen, the size of a pea, a shilling, or less ; these are generally corered by 
thin sipamm, which are hard, adhei'ent, and gray, and seated iipona copper^ 
tinted basis, which is smooth and shining, not elevated, not [lapahtr, not 
red, as in simple alphoa ; a white rim surrounds each patch, and this is fortueil 
by the loosening of the cuticle around the circumference. These EjmtB ar» 
scattered over the arms, breast, face, and trunk generally ; and when the 
palms of the hamls or soles of the feet are diseased, the skin is dirty, hudi, 
scaly, cracked, and fissnred. On the palm of the hand is exhibited a red- 
dish s|K>t, over which tlie cuticle becomes hardened and yellowish ; the sur- 
facu then cracks, and the diseased action tands to spread, producing a " nA, 
inflamed, hot, cracked, exfoliating surface," and assumes an annnlate, serpi- 
ginouB, or tubercular form. If the central part heals (lepra), it is called 1L 
palmare annulatum : these palmar and plantar diseases are tertiary sym|i- 
toms. Hai'dy has desciibeil a syphilide cornee ; it is merely plantar or pal- 
mar psoriasis, in which the epidermis hardens very much, and the coppery 
areola is well marked. Devet^c thinks that the [tsoriasis palmaris, when it 
a9ect« the palm of the hand rapidly, and the palmar aspect of the fing«ra u 
well, with pretty free des(|uamalion, is pityriaaiB rubra, and not psonMOa 
at alL Syphilitic lepra is often intermingled with the papular and tnbercalar 
varietieB of eru|)tion, 

Ditiffjui»i». — There are seven leading features which, taken togetlier, an 
positively diagnostic of syphilitic alphoa. (1) Alphos limited to tht- palnis 
of the hands and soles of the feet, Li iu the majority of cases sypliilitic. 
(2). The disease does not attack the elbows and knees by predilection as in 
the simple forms. (3) It is generally displayed in little circular ]>xtcbes, 
which ai-n isolated and not confluent. (4) The patches have a [leculiar 
whitish line circumscribing tbem, due to the elevation and attachmnnt of 
the cuticle. (5) The squaioo) are thin, small, gray, and repose nj-on a cop- 
pery base. (6) There are generally significant co-existences of bpecifio ia- 
fwtion. (7) Copper-colored maculn follow in the wake of the diaease. 



TirB^KUI.AX BTFHILOtlEBX. 



^^r TUBERCrLAH BVFBILODBRM 

la decidedly a common form of eecoudaiy syphilis, the tu1>erctes for proo- 
tical purposes being regarded om lui exaggerated condition of papules: tliey 
vary a good deal In size (from that of a pea to that of a nut) and form, but 
»re always iudoleuti, snd mostly occur about the iace, especially the nose, 
forehead, aiid side of the he-ad. They jMssess a coppery tuit, aud are flat 
und hard; when tliey ulcerate, which they do when large, they become 
covered over by thii'k and black adherent crusts. The tubercles may be 
aggregated and iii grouj^s. The patches increase by the ceutrifugal growtli 
of tubercles, aud in the diseasa as uow described, the edge ia generally 
bounded by distinct tubercular elevations ; the atii'face is muddy and cauheu- 
Uc. When the central jiart clears, as it were, the disease closely resembles 
epni ; and when the tubei-cles di£a|>pear, the deima often appears to be 
atrophied, so that cicatrices are left in connection with a considerable degi-ee 
of maculation. The tubercles may at other times be disseiuinated. This 
may be regarded as papular syphilis in a marked degree ; the tubercles, 
rather larger in size than that of p«as, are not an'anged in any particular 
order, but are seen scattered over the trunk, the back, and the face; they 
are very indolent, do not ulcerate, and are only covered by squanuu to a 
very slight extent. Several tubercles muy collect, so that a ring is formed, 
the enclosed centi-al area being tolerably healthy. 

The ditiitreiice in the graupixig of the tuliercles has j^ven lise to the divi- 
sion of iJie disease Into tubercula circtiiii»criptu, ilisHemiuata, annutata. Id 
these no tilcevali'>n occurs, but in other instances the tubercles do ulcerate, 
smd this form ia called — 

I'livraling tubercular in/phUide. — Tlie ulceration in one instance may be 
deep, in the other superficial ; the lirst condition is the syphilide tubeccu- 
leuse perforaute (perforating or deeply ulcerating tubercular syphilide). In 
it the tubercles are large, few, livid red, with a copper-colored areola, having 
a tendency to ulcerate deeply, with accoiupanying pain and discomfoi't; the 
aahy-colored and foul ulcei's, wtiich may become conlluent, ci-ust over, the 
ulceration meanwhile eating more deeply, ttie crusts being i«]ieatedly ahed 
and reproduced. In this way the nose may be destroyed and lost, the dis- 
ease retiembliog lupua : it is most common about the face. Sevenj ulcera- 
tion is geuerally a symptom of tertiary syphilis, and accompanies mai'ked 
cachexia, indurations of the perioet«um, syphilitic caries, etc. When the 
ulceration ia superficial it creeps along the surface, and then we get what is 
called the aerpiginous 8y|>hi]ide. It diffei-a from the perforating variety 
chiefly iu the fact that the ulcerution takes place in a superficial manner, 
creeping over the surface ; the form varies somewliut — it may be in bands 
or drcles; the sui'face of the ulcer becomes covered over with blackish 
crusts, which fall and are reproduced froui time to time ; the tiibei-cles 
thp-Ulsclves are large, and, if the ulcers heal, distijict livid cicatrices remain 
Whind; if the tubercles become conUuent, the ulcemtion Is more marked. 



152 SYPHILITIC ERUPTIONS. 

Another condition is tlie fissured tubercle ; it is smallish, and is notfbed to 
be the seat of a linear ulcer, or a fissure in its centre ; there is a good deal 
of ])ain ; and a thinnish ichor is exuded ; it is seen about the side of the 
nose, lip, scrotum, and anus. 

Tliere are then two distinct aspects of tubercular syphilodermata, — the 
'idcernting ami Uie non-fdcerating / but even these are not absolutely sepa- 
ratoil the one from the other. The non-ulcerating may be subdivided into 
disseminated and aggregated. The tubercles mostly disappear by resorption. 
The ulcerating form may be likewise subdivided into ]^)erforating and 8eq)i- 
ginous ; but even a mixed condition of these two may exist. A syphilitic 
lupus or lupiform syphilis has been described. The chai-acteristic of lupus 
is the attempt at re)>air, which is so far successful that it gives rise to pe- 
culiar indelible cicatrices, and when tubercular elevations are accompanied by 
a duU-rtnl tint and succeedeil by deep ulcei'ation, with more or less scabbing, 
sanious discharge, and attempts at rejxair, ending in partial cicatrization, the 
distvise is tonueii sypliilitic lupus ; but it is a bad one, as likely to confuse 
between lupus and syphilis. 

Jhagmms, — Syj>hilitic ulcers are likely to be mistaken for lupus ; the 
former have sliaq^ly-cut eilges, tubercles around which are /wirr/, smooth, 
dr}-ishj dense, sliining, and cop[>er-culored. Tliey occur in i)eople of middle 
tig*\ are aoci^nnmnieil by concomitants of syphilis, and the ulcers arefauly 
dirtt/^ <f4cAy, exuding <iii ichor y and the tissues around are infiltrated and in- 
duraunl ; in the lupus ulcer the eilges are not 8harj>ly cut, but thickened 
and nnindtHl ; there is no oopj>er-ct>lor : the tubercles are fofty red, quatir 
g^'latinous; the jkarts around are |^nful and ivdematous: it ofu^n occurs 
alvnit the fact* alone in goung pi^>pU: theiv is an entire absence of syphilis, 
and the uUvrs ari* iVrti** and drg, 

SMuotiuies a sxpliilitio ulivr originates in jrti?»rM/'iiMY>M* induratiotu / these 
an» ol^e<*»rvt\i in vorv old->taiuUng i^a^e^ They are calltnl tumores gUDimati, 
or tulvrctila gummata ; thev an- hanl and alK»ut the size of nuts or walnuts. 
Pn»5i«»ntiv tiie suiiact' over them Inwuies reil and tender, and ulceration 
cvnuuuuuvs : but it is > er> indolent, inde^xl it has no tendency to heal ; gives 
exit to a little tlui.U sv^aUs Si^uu'whai, and is not |«iuful. 

Just as wo have crx^wths and eruptions of the ctitaneous. so have we 
^milar alf^vtioiui of tht» nuuvus, surface* ; it is only iKHsiful to rvfer now to 
th^>c^« ohan^^ whioh an^ ol<e**rvable to the eve, and which are seateil especially 
at the junotion of the skin ami niuoxnvs uHMubraii*^ : hence }iarticularly at the 
oritioe* of the natural outtoi* : but no; only hetx\ fv*r any pdtft of the sur&oe 
which is habitually lvitht\i in Avn^tion, aud aotiM u|x*n by Inat, is liaUe to 
the sauH^ kind of \h>*^aA\ This Ivmiu of >yphiiv^irrv.ja ha;> K»en called vejje- 
tati>o svixhiiis, and is i;v^:i^>M nuv^th in th* tVu.a!e alxv.;; the vuh^: in the 
i"^'.ii\i a\xM;t the «iov,:h, b^isuvks, ai.d Ar.i;s; av.u :Ke iv:;is in the adtdt. 
Then* an* tx^o si^vit> i;r»uvus ;ulvrv!«Tii a: d x\^r.vi\;, ■■:*•**; a ^wins^. Mueotw 
tv.lvn,*ios ^«v Kksr.^-^r.:*: } It'rs:.^^^ an* om'r.lar f.*: tV >a:ii-us, of sof^ k^ 
a:'.d iwi, aiHi taa\ Vv dt*schb<\i vn;r:I\ a* m^wr;* tVNS'i^Hvi v u: v^f xuucous mem- 



TUBERCULAR SYPHILODERM. 153 

brane f they become more or less ii-ritated, the parts around being also in- 
flamed, at the same time that they give exit to a fiEiint, pale, viscid secretion : 
they may ulcerate, or become pedunculated, when they are to all intents and 
purposes condylomata ; they frequently spring up in the seat of an old sore, 
and always cause considerable local discomfort. Condylomata ai*e simply 
pedunculated little warts, occasionally sessile, differing from mucous tubercles 
in the fact of being firmer and not giving rise to ulceration or secretion. 

Syphilitic Alopecia is pretty common; the hair may thin out, if the 
cachexia be marked ; or it may fall off in patchy form. Tlie diagnosis is 
made by a process of exclusion, and the positive existence of latent or 
developed signs of syphilis. 

/Syphilitic Onychia may attack the structure of the nail itself, or the 
matrix especially. In eady infancy (under a year), subacute onychia 
attacks several fingers at one time in conjunction with iritis, otitis, snuffles, 
etc. ; it ends in exfoliation of the nail, and is not unfrequently attended by 
a papular rash, etc., over the suiiace of the body. The local symptoms are 
pain, redness, swelling around the base of the nail, followed by suppuration 
and ulceration of the matrix, with loss of the nail. This state is sometimes 
a secondary symptom in the adult, but usually the matrix escapes ; there is 
no pain and no exfoliation, but the superficial layers of the nail become 
affected. As Mr. Hutchinson described it to the Pathological Society, it 
begins at the root, where a ^' semilunar furrow is seen extending across it ; 
the outermost layer is destroyed over the entire lunula, and a ragged border 
overhanging that part is presented by the distal portion ; by degrees, as the 
nail grows, the diseased margin is pushed further and further on. The 
nails appear dry and brittle in texture, as is shown by the fissured and 
broken condition of the free edge.'' Several nails are attacked at the same 
time and that symmetrically ; the progress is very indolent indeed. 

The so-called tertiary symptoms are psoriasis and erythema, palmaris and 
plantaris (erythematous, Wilson), mucous tubercles, ulcerating tubercles, 
tumores gummati, and the large syphilitic ulcers which occur in cachectic 
subjects who have long been impregnated by the virus. 

EryOicma and Paoricisis of the Palm of the Hand or Sole of tlie Foot — In 
cases where we can trace the history of syphilis and its cachexia, these two 
forms of disease are seen. A red spot appears about the centre of the palm 
of the hand, it remains dry and cracks, and assumes the form of psoriasis 
(lepra). It creeps farther and farther over the surface, sometimes in the 
form of rings, the central part clearing as r^ards the redness, but remain- 
ing dry and discolored. Often the affection assumes the aspect of a tubercu- 
lar eruption. An erythemato-squamous eruption, somewhat like lupus, but 
not 80 "vascular" and copper-colored, occui-s in old syphilitic subjects 
about the forehead and other parts. The diagnosis from simple eczema 
palmare is sometimes difficult, but the exfoliation, earthy staining, tubercu- 
lar aspect, and especially the " ringed " character, if it be present, aid effec- 
tually in connection with other sjiecial concomitants. 



154 SYPHILinO EEUPTIONB. 

TREATMENT OF SYPHILODERMATA. 

This consists in the first place in subduing the feverish symptoms whidi 
accompany the eruption — in other words, the syphilitic fever ; secondly, in 
toning up the system to help us counteract the mal-action of the poison, 
and to favor if possible its elimination or annihilation. Our treatment 
varies considerably according as the cutaneous eruption takes the a&pect of 
a secondary or tertiary syphilis, and also if it be hereditary ; and the first, 
or only a recurrent attack. In secondary syphilis the remedy is mercury^ 
in ted^iary disease iodide of potassium. 

Now I discard the bichloride, blue pill, and all other preparations of 
mercury, save the bicyanide, and I now use the bicyanide exclusively. It 
is given in yVj grain doses, in pill, with extract of gentian, quinine, or 
opium, as the case may be, twice a day ; whilst iodide of potassium, in five- 
grain dose, at first twice and soon thrice a day, with spirits of ammonvii is 
given internally. Where the disease is extensive, the calomel vapor bath 
twice a week may be added. This is my treatment, and I am quite satis- 
fied with it, especially with the bicyanide, which is a more soluble com- 
pound than the bichloride, and has none of the irritating qualities of the 
iodides. I never have salivation, nor other serious ^' mercurial '' sequences; 
and, given alone in the slighter forms, it acts most effectually. The iodide 
of potassium is given with it at once when the disease is papular, tubercu- 
lar, or ])ustular. In all cases I have regard to my patient's constitution, 
and give remedies calculated to check its ill tendencies ; if necessary, the 
mercurial course may be continued till the disappearance of the eruptiooi 
and a course of mineral acids or quinine shoufd be given. 

In the s({uamous and pustular syphilides mercurial treatment is called for. 
In the ulcerating forms, if the patient be well nourished and pretty strong, 
tliere is no objection to a mercurial course ; but where cachexia is marked, 
and the patient's condition is one of e\ddent debility, iodide of potassium 
with cod-liver oil, or iodide of iron and good food, is the best treatment. 

In cachectic subjects who are debilitated, restless, and irritable, opium 
given internally is of much service. In reference to iodide of potassium it 
must be borne in mind that its use is beneficial in direct proportion to the 
duration of the disease ; hence, when nodes, tubercles, caries, and seoondaiy 
ulcers arc present, when mercury has been fully used, or seems to faiL 

In all cases the exhibition of decoctions of vaiious woods is advisable. 
The com]>ound decoctions of sarza and guaiacum are the best ; they keep 
the skin and bowels fi-oely acting, and thus very materially help the elimi- 
nation of the ]>oison. Wlien a i>atient is under the influence of mercury, 
he should avoid stimulants, cold, and other sources of irritation and catarrh ; 
the drug itself acts by its effect upon the system at large ; the exhibition 
then should be continuous, and not interrupted. If it do not after awhile 
seem to produce much beneficial result, then its use should be discarded, 
and the iodide of i>otassium used with tonics. Local measures are only 



TREATMENT OF 8YPHIL0DERMATA. 155 

urgently called for in those instances of tubercular and ulcerative syphilo- 
dermata in which destructive action can be thereby checked. Should sali- 
vation occur at any time, the mercurials must be omitted, or given cautiously 
and with attentive watching. In no case should it be our object to in- 
duce or push the drug to the point of salivation. In giving- a mercurial 
bath, the patient is seated upon a chair and covered with flannel, and out- 
side this by an oil-silk quasi-coat or bag ; beneath the chair is placed a 
copper bath, containing a pint or somewhat less of water ; upon this is 
placed a tinned iron plate, which holds the mercury to be sublimed; 
beneath the bath is placed a spirit-lamp ; the patient, aft;er the latter is 
lighted, is '^ exposed to the influence of three agents — heated air, common 
steam, and the vapor of mercury; in about five minutes perspiration comes 
on, and the patient should be subjected to the influence of the bath for 
some ten or twenty minutes, when the lamp should be removed, the patient 
allowed to cool gradually, and made to take,^' as Mr. Parker further ob- 
serves, ^' a warm drink of decoction of sarza or guaiacum." 

If the preparation employed be the bisulphuret of mercury, about one or 
two drachms should be used ; if calomel, from ten to twenty grains ; if the 
iodide, ten to twenty grains ; the oxides and the bisulphuret are the mildest, 
the iodides the strongest fumigants. The bath may be used once, twice a 
week, or even more, according to circumstances. 

Inunction is another mode of bringing the system under the influence of 
hydrargyrum. Continental dermatologists advocate a plan, which Wilson 
briefly defines as " a triple compound of starving, purging, and sweating," 
and which he mentions with commendation ; it is the so-called Zittman 
treatment, but is one which compels the patient to give up his usual employ- 
ment, to take to bed for a fortnight or so, and on this accoimt is almost in- 
applicable in a general way. The patient who has syi^hilitic disease wants 
to get rid of it without entering upon any plan of medicine which would 
disclose his secrect, and take him away from his work ; most men could not 
aflbrd the time ; however, the plan is as follows : — First day, a purge (calo- 
mel and jalap), and three meals of broth ; up to the fifth or sixth day four 
pints of the Zittman decoction are taken daily ; of these four, two pints are 
made of the strong and two of the weak decoction {vide formulary), with 
each day two ounces of meat and two of bread : on the sixth day an active 
purge, with broth as before ; the seventh till tenth repeat the drinks, and 
meat and bread : this continues till the fourteenth day or so, and then the 
patient is kept on low diet, allowed to get up, but still continues to take a 
small quantity of the decoction. If convalescence is tardy or insufficient, 
the same treatment must be recommenced. 

It has been a matter of much dispute whether infantile syphilis should 
be treated upon similar principles as those above described. For my own 
part, I should be exceedingly sorry to be an infant affected by specific dis- 
ease and not treated by the drug mercury, in addition to chlorate of potash, 
and syrup of iodide of iron. The best plan is to rub a little mercurial oint- 



156 SYPHILITIC ERUPTIONS. 

nient into the solo of one foot at night, and where the mirse or mother is 
tainted, to give the iodide to her, and therefore to the child through her 
milk. The mercurial requires to be used only a few times, and at each rub- 
bing a piece of ointment about the size of half a pea. 

Ths Local Treatment of Syphiloderniata, — ^The erythematous forms re- 
quire no special application, except they be obstinate, and then a white pre- 
cipitate ointment may be used ; the squamous and papular are relieved by 
calomel ointment, bichloride lotion, and nitric oxide of mercury oiutment& 
The tubercular and ulcerating forms of disease are those which require 
8i)ecial local medication. In the tubercular form the acid nitrate of mercury : 
biniodide, and other mercurial ointments, are those most especially useful ; 
the former is used to destroy the little indurations, and should be used 
cautiously ; the biniodide in glycerine, applied with a brush, is often most 
efficacious in obstinate cases. Syphilitic ulcers may be dressed, if painfnl, 
with a solution of watery extract of opium, or be dusted over with calomel, 
or be stimulated with the nitiic oxide of mercury ointment, dilute nitric 
acid, chloride of zinc, and borax lotions, or treated by the local application 
of mercurial vai)or. In the appended formulary several remedies will be 
found in i*eference to the genei*al and local treatment of syphiloderma. Sw 
numbers 13, IC, 17, 18, 41, 71-7-8-9, 81, 92, 110, 114, 121, 143-5, etc 



CHAPTER XVI. 

LEPROUS DISEASES. 

Under this head I include the time leprosy or Elephantiasis Grfecomm. 
The disease of the leg, known as elephant leg or elephantiasis arabum, and 
DOW oalled bucnemia tropica, is not thought to have any relation to true 
leprosy. 

JElephantiasis Ghrcecarum or true leprosy is a disease of which I have seen 
many cases during the last few years, especially in Syria, in Egypt, and in 
England. Three or four cases have come under my notice in England, and 
at the time of penning these lines a man is under my care in Charing-Cross 
Hospital with the disease exceedingly well marked. Space only allows me 
to notice the disease briefly. Its geographical distribution I must jiass over, 
and refer for this and other points to the recent Leprosy fleport of the Col- 
lege of Physicians. The disease is specially marked by the occurrence of 
discolorations and tubercular deposits in the skin, accompanied by anaesthesia. 
In some cases the deposit is well marked ; in othera it is less ; only the 
aniesthesia is comparatively a more prominent feature — hence we have two 
forms, tubercular and non-tubercular (or aneesthetic as it is often called). These 
are mei*ely varieties of one form of disease. Those cases that present them- 
selves to the physician in England (and which are mostly mistaken in the 
early stage for syphilis) give some such history as the following : — That 
they have lived a long time in pai'ts of India or elsewhere where the dis- 
ease is endemic ; that they have had repeated attacks of " agiie and fever," 
which has pulled them down very much ; and that some years afterwards 
brownish stains began to appear in different parts of the body, and upon 
these small brownish tubercles formed, first of all about the nose and eye- 
brows, or ears or neck. The next thing noticed was a loss of sensibility 
about the little finger and corresponding side of the palm of the hand, with 
wasting of the muscles between the forefinger and thumb. 

The first change in the skin has been desciibed by the patient I have had 
under my personal observation as a dark dull coppery discoloration ; one that 
should never be regarded as syphilitic, for the simple reason that syphilis 
never induces staining per se over an extensive area of surface. The two 
phases of leprosy must be desciibed in detail apart. 

Tfie tuberc^ilar form commences with malaise, — an indefinite feeling of 
something wrong — rheumatic pains — a felling asleep of a limb frequently 
(generally referred, says Dr. Bowerbank, to some chill or sudden change of 
temperature), or with pricking sensations about the hands and feet. But 
some authorities declare that brown patches come first, or that there is a 



158 LEFROUB DISEASES. 

numbness about the hands so that the patient cannot grasp so well asusuaL 
At all events very soon there is a dull red discoloration in patches, then the 
face begins to flush and swell ; it looks over-heated ; then the limbe and 
trunk brown, and little tubercular formations make their appearance, fimt 
of all about the face, especially the ears, on the discolored patches. From 
this moment tlie disease steadily progresses. The tubercles vary in size, from 
that of a pc^a to that of a walnut ; they are soft, smooth, shining, of a duskj- 
red color at first, becoming presently brownish-yellow, or bronzed. In the 
early stage, the sensibility of the part is often rather increased, in conjie- 
quence of the pressure exerted by the blastematous effusion upon the nerves; 
but after a while this morbid sensibility becomes altered in character, and, 
from the greater degree of morbid change, diminished sensation sets in, and 
increases until it becomes decided amesthesia. On stripping a patient 
after the disease has lasted some time, we notice deep-brown staining or 
patches varying in size from a shilling to the area of the hand over the front 
and back of the trunk, the arms, all round the neck, and of course all over 
the face, separated, save on the face, by healthy skin. Upon these patches 
are the tubercles in little parcels, or collected into one or more flattened 
elevated masses studded over the sui*face. 

The tubercles are most marked in situations where there is much lax 
cellular tissue ; therefore about the face, nose, lips, eyes, mouth, and ear. 
The diseaae may be more or less partial. The sebaceous glands now take 
on a hyper-action ; hence the skin is oily and shining. The increase in the 
development of the tubercles ))roduces tenible deformity ; the surface feeb 
thickened, knotty, or uneven ; the face is altered completely ; the edge of 
the mouth and lips, the eyebrows, the ala) of the nose, the eyelids, are all 
distorted and tliickened, the whole integument being dirty and sallow-like^ 
and the various aspects presented by the patient have been described by 
the terms leonine, satyr-like, etc The sebaceous glands become enlarg^ 
When the lower limbs are affected, the disease is generally most marked 
about the lower }»art of the thigh and ankle. Coincident ly with theie 
changes aiuesthetic points ap)>ear in the centres of the oldest patches. In 
tlie cases I have seen, the parts supplied by the ulna nerve were iuseusibK 
and this has only Ix^en discovered by accidentally burning or scaldingf 
which has not l)een felt. Tlie ulnar nerve can be felt enlarged and cordy 
above the ellx)w ; a good deal of [tain of a neuralgic chai'acter acoompanie* 
the aiHHsthesia. Tlie muscles of the hand waste, the fingers cannot be op* 
posed, nor the hand gi'asp [)roperly or pick up small things in consequence^ 
even in an early stage of disease. Not only the cutaneous but the niucou^ 
membranes participate in the same change. Tlie mouth, the i>alate, th^ 
fauces, the trachea, the nose, the eye, arc all affected by deposition of wmr 
terial in their mucous surfaces. The internal glands — e, </. the liver — ^in." 
deed, all the internal organs, vrith the exception of the jtancreas, are finally 
affected ; the systeui is generally infiltrated. The patient^s general condi" 
tion all this while ia not serious. He is morose, low-spirited, dull, and care" 



LEPROtre DIgBASES. 159 



leas ; Iiut now his troultlea are comineiiciiig iu earnest. His voice, his sense 
of smell, of t»Bte, etc., are affected, and the lanie has come for ulcerative 
action to set in : the tumors soften, ulcerate, and pour out an unhealthy, 
ofTeusive secretion, which crusts over the sore from where it conies; the 
Attempt at healing often fails. The eye is destroyed, the mucous surfaces 
of the internal parts ulcerate — e. ff., the nose anil its bones are destroyed. 
Dinrrhta from intestinal ulceration is a Bad complication : the bonus become 
■Twrious. hectic seta in, and the patient dies. Ulceration is not bo common 
in India as iu Europe. The duration of tultercuhir ctephantiaaia, according 
to Dm. Danielssen and Boeck, is nine and a half years. But twenty or 
even more is common in other cllniates. 

EUjihanlians AtMnf/ietica (.lHtE«('(e(£c Lejyrogi/). — In the tubercular 
form the deposit shows itself in a marked manner, implicating the nei-ves 
more or less ; but in the anaesthetic variety the disease alfects primarily tJie 
nervous trunks, and leads to a lowering of nutrition, onrasthesia, and subse- 
quent destructive changes. There vtay be little of the tubercular aspect; 
luimsthesiii is the great sign ; the muscular power is deficient, but paralysis 
is not a marked feature ; " in a word," as Mr. Wilson has it, " inteniibility 
and atrophy are the distinguishing featui-es." 

[It is not rare, however, to see aniesthetic leprosy partaking of the 
characters of the tubercular form. Tliis is the iniaxdform of disease, and 
it occurs in India in about 15 per cent. It generally eonimences with 
eruption, which is usually of the white (morph<ea alba) variety : it also 
begins in one-third of the cases under 20, and is i-ai-e after 40. The face 
exliiUta the tubercles ; two-thirds of the subjects attacked are moles ; and 
it is a fatal Ibnn, hereditary ti-ansmission being strongly marked. (Carter.) 
This is the general character of the amesthctic variety, as compared with 
the tubercular. 

There are then transitions between the difierent forms of leprosy. It ap- 
pears that the blastema effused in the aiuBsthetic variety is somewhat more 
tmusi>an<ut, not so opaque as in the other forms.] 

The antratltetic variety commences witlk much the same general symptoms 
u Xhe tubercular foiiu. It appears to originate, so far as Ic.cal symptoms 
«* concerned, by many subjective sensations of heat, shooting, burning, 
pricking sensations about the hands or feet, with more or less weakness, fol- 
lowed by tendemesB, pain, and : welling along the course of the chief cutantv 
mis nerves — e. g., the ulnar, the median, the sa[>henous, etc., ending in numb- 
ness and insensibility to irritants. The integuments get parched, dry, shriv- 
elled, perhaj>s covered by a clammy sweat, and desquamate. Subsequently 
to tliia, the eruption makes its appearance : it ctaisists not only of erythema- 
tous patches, but especially of buUie, which are of large size, occuiTing on 
parts previously anessthetic : these bi'eok, and their place is supplied by 
BujvrBcial ulcerations, which, after scabbing, leave beliind white, hard, hair- 
less, glandleas pstehes of morphiea alba. Dr. Vandyke C'art«r has specially 
itudied this morphtea, and I therefore append his description, in which I 



IW LKPBOnS DIBEABE8. 

agi-ee, tlitia : — " Patches or spota of a circular or annular form, tbree^iui'- 
tera to thriio iucliea or moro in (liami*t«r ; edgea i-aJaed, of a pinkish bile ■ 
free from Bcales, alightly crack«il or wrinkled ■ centre depressed, pole, dry 
glistening, havinga tendency to spread and join so as to cover larger atiaem." 
Tbe central jiart of these patches is always aniestlietic, completely in c«8w of 
Bome duration, and feels hard to tlie touch. The patches may vnry mucli by 
the presence of 'cales or alight desquamation, or alight ichorous exudation ; 
the hairs of the part are atrophied, and it is said not whitened ((Jarter), they 
are subsequently lost. The glands also sutfer in like manner. This typical 
form of eruption is the barae of the Arabs, the Uuce of the Qreeks. Th* 
result of carefid intpiiry seems to show that these patches are the result of 
changes in the nervous supply, tliat they run the one into the other, and 
vary in aspect from simple white atrophied circles to large " isolated bal 
blended patches," witJi or withoiit red vascular margins, passing throuj^ 
the stages in which the centi'e is first red, then brown or i^ale, and surround- 
ed by a distinct pink border of veBsels. The centre of every jiatch gndual- 
ly becomes more and more ana<sthetic. The chief seats are the back of the 
hip, the front of the shoulder, about the elbows, and on the fore[iart of the 
knee, over the temples, cheeks, trunks, and limbs. The eruption is symme- 
trical, and often precedes the anWKthetic form. It existed alone in 14 of 
186 coses (Carter), and in 48 of 186 cases of auieathetic leprosy. 

Coincideutly with the changes above de^ribed, the body generally wnstM, 
especially its muscular system : hence the tiugers become distorted, and in 
a peculiar manner, the first phalanx is bent backwai'ds by the extensor; ttw 
others are flexed : not only does this happen in the hand, but the feet and 
other joints also are distorted and renderad prominent. The buUat ma; 
give rise to deep, ragged, foul-edged ulceration, the base of which tuMj faa 
sensitive, proving the superficial character of the disease. The face is do* 
much disfigured ; it looks haggard, shiivelted ; the skiu is what ia tenaei 
'' mummified," or lax and loose. The mucous sui'faces are exposed, in con- 
sequence of the " sclerotic " or hardened and contracted stat« of skill. 
Tbe deeper parts now become aiFected ; a joint is seized with acute pain, • 
sinus forms, a piece of bono ia discharged, and the sure heals. ' Dr. Carter 
thinks tliis is an unusual mode (by necrosi") ; be believes that the deep 
parts 81*6 removed by " interstitial absorption," without \ia,ia or reactiouuy 
activity of any kind : tbe termintd jibalangea are the first bones to anfier^ 
and the disease, by steady progression, removes Imue after bone. The mu- 
cous surfaces became involved ; they are infiltrated with " blastema,'" but 
not to tlie same extent as in the tubercular form ; hence there is not somudi 
diarrhtea or suppuration as in the latter disease; the patients live, on an 
average, about us long again — eighteen to twenty years. The ulcers of the 
aurface are sujiiiosed to be due to irritanta acting from without upon devi- 
talized (anesthetic) parts ; hence they are seen in those accustomed to hard 
manual labor. In the latter stages, the general health suffei-s very mat«- 
rially, but not to the same degree as in the other foim of leprosy. I^^^^ 



LEPROUS DISEASES. 161 

tient may die, worn out bj exhaxistion, bodily and mental, or be cut off by 
some intercurrent disease. 

The Pathology of the Disease, — Elephantiasis is a blood disease of mala- 
rial origin it is now generally thought, which shows itself by the effusion 
into the tissues of an hjrperplastic material. There is this difference, that 
whereas in the tubercular form the deposit, besides being more opaque, is 
deposited chiefly in the fibro-cellular structures, in the anesthetic form it 
is more transparent, and is deposited, par excellence^ in and outside the 
nerve-tissue. In the tubercular form, the fibro-cellular coats and structures 
of all the organs except the pancreas are found infiltrated by the peculiar 
deposit ; in the aneesthetic, there is often an absence of this feature in the 
internal viscera and their coats. In reference more particulaiiy to the 
aneesthetic variety, Dr. Caiiior's observations may be briefly summed up 
here. He found the brain, spinal cord, and the roots of the nerves healthy. 
Dr. Fabre, who studied the disease in Brazil, noticed the brain to be atro- 
phied, its ventricles to contain fluid, the glandulsB Pacchioni numerous, and 
oftentimes a circumscribed suppuration in the membranes. Drs. Danielssen 
and Boeck differ from Dr. Carter : they state that the spinal cord and its 
membranes are altered ; the latter being infiltrated with an albuminous 
deposit, a layer being found between the arachnoid and the pia mater ; the 
cord itself being indui'ated, its gray matter discolored, yellowish, and devoid 
of vessels : the sheaths of the nerves and the various ganglia being similarly 
affected. They think the pnmary seat of the disease is the spinal cord. 
Dr. Carter, on the other hand, contends that the disease commences in the 
superficial nerves, and travels towards, but does not reach, the spinal cord. 
The sympathetic nerves are healthy ; the heart, lungs, and intestinal canal 
healthy (Carter) ; the liver and kidneys fatty — in which all agree. The 
muscles generally are wasted and "fibrous," but not fatty, as the rule. 
The blood contains a more than ordinary quantum of albumen. The most 
important changes are observable in the nerves themselves. Dr. Cai-ter 
says the nerve is swollen, dull-red, or gray, or semi-translucent, rounded, 
and firm. The funiculi, not the connective coat, is the seat of disease ; the 
nerve is evidently very tense. The place of " the clusters of nerve-tubules " 
is supplied by the albumino-gelatinous infiltration which has pressed upon 
them ; the deposit sun-ounds the nei*ve-tubules, *^ mapping out, as it were, 
the area into polygonal or rounded spaces, in each of which lie the remains 
of one or two altered nerve-tubules." Hence the chief features ai-e Jirni- 
nessy opacity y and enlargement^ from foreign deposition. This is chiefly 
marked in the compound trunks which are situate most superficially, and 
in the '* cutaneons nei'ves just after perforating the deep fascia : " those 
chiefly diseased are the ulnar, radial, and musculo-cutaneous ; and they 
may exhibit these changes over the space of an inch or more ; sometimes, 
indeed, a greater distance along the parent trunk towards the spinal canal. 
Dr. Carter sums up the microscopic appearances thus : — The funiculus is 
" unchanged or slightly thickened, and marked by fusiform granular masses, 
11 



162 LEPROirs DIBRASES. 

or more (liBtmct oval granular nuclei of full size;" from its inner nsjiect 
" septa pnHG, which map out eo curiouslj' the area of the diseased funiciilus. 
These ai-e composed of a uucleated fibi'oua tissue, very distinct and vinu': 
the nuclei, varying in siie, are granular ; they have ocuaaionally ap^iearpd 
to be free, and, when smidl, resembled at first eight the ends of the WHsted 
nerve-tubules in a transverse section. The space inclosed by the septa it 
polygonal in shape, and from ^^y to ^jiuj^jn. in diameter. It is occupied 
by a clear homogeneous, re&aclile substauct?, in which the altered Derv«- 
tubules are imbedded ; the latter ai-e usually much changed, their medul- 
lary sheath corrugated, and their contenle granular, luiiform (?), and firm:" 
there may be simply empty walls, or " no trace at all." The I*a«cimaa 
ontain the same deposit, and the tactile corpuscles are atrophied. "Hwi 
skin is infiltrate by the same blastematoiis fliiid, fonning after a while • 
delicate network of fibres, in the interstices of which lie whitish gmnular 
and fatty mutter ; Aft«r a while the fibres go, and the foreign Duit«rial ia 
wholly cellular, the cells being oblong^with a very large nucleus, nvnrly 
filling the parent cell, and containing sevei-al distinct granules, Tlio vesscJ* 
and sweat-glands are after a wliile deeti-oyed. G. Simon I)elieve8 that tfae 
skin, the hair, sweat, and sebaceous follicles hypertrophy at the same time 
that there is a dejiosit of corpuscles, containing granules scattered through- 
out the meshes of the fibrous tissue. The bones are " rai-efied " bv '' mole- 
cular destruction." As to the origin of the nerve disease, " it ap[iettn 
that, first of all, a clear material, probably albuminous, is deposited between 
the nerve-tubules, and in this nuclei, and subsequently fibres, are de- 
veloped, and the deposit itself may become fibrillated. The nuclei are often 
^'g^t ioVbi tVot "I- i" length, and -g-^ iu. in diameter, clear, round, and 

The Caufea of Elej^hantinsis are not well made out. The disease, accottl- 
ing to Dr. Carter, appears in India to be most ])reva]ent, as regards social 
standing, iu the following classes : — Native Christians, KlBrnthas or low- 
caste Hindoos, Miissulmans and Parsees, vegetable-feeiling Hindoos, etc. ; 
Europeans are generally exempt. Tliere is some little difficulty in A3cer> 
taining the influence of sex. Tlie seclusive life of the females in countries 
where the disease abounds may explain in some degree the fact of ita being 
more freijueutly eetn in iiialeB. 
Indies the number of the tw< 
opinion, however, is that males are much i 
Of 543 de»ths in Bombay duriug twelvi 



e of tlie lej>er aaylums of the Wetit 
i about the same." The ( 
lually leprous tb«n fli 

e years 409 occuiTed ii 



yet of 906 leprous patients treated in 8t, Geoi-ge's Hospital nt ] 
Norway, from 1S41-C, 401 were males, 445 females. It is oom 
Norway as in India, in the fish districts, where the folk eat qnantitil 
foul fish ; and Dr. Carter further obeerves, with regard to occn[Mttiiin|fl 
many of the lejiers " are fishermen, many ryots, all of whom lived i 
leas on rice and dried or salt fish ;" but then it is common vben % 



LEPROUS DISEASES. 163 

conditions are not fulfilled. It is generally- now regarded as having a 
malarial origin. 

Hereditary tendency is certainly an efficient cause, and is most marked 
when it is on the male side, and if children are begotten by lepers far ad- 
vanced in the disease. Of 623 cases to which reference is made in the 
Leprosy Report of the College of Physicians, including, those of Dr. Day, 
Dr. Porteus, those reported from Pooree, Nagpore, and Bdeck's, in 287 
cases an hereditary taint could be established, and many, it is well known, 
deny its existence in families where it is afterwards discovered. 

Age has some influence ; the baras generally appears before the age of 
twenty, the tubercidar sooner perhaps than the ansssthetic form, which gen- 
erally commences before the age of thirty. Damp and humidity, uncleanly 
habits, filth, and poverty, are conditions favoring the occurrence of elephan- 
tiasis. The anaesthetic disease is most common in India. Of 186 cases 
(Carter), 67 were anaesthetic, 40 mixed, 17 tuberculous, 14 exhibited the 
** baras '^ only, and 48 were cases of anaesthesia complicated with bai*as. 
There is no reason to think that syphilis has any relation to elephantiasis. 
In 64 of the 90 reports of Indian medical officers on leprody, this connec- 
tion is absolutely denied. Leprosy is not contagious, it is believed. If it 
be so, it is held only to be so when the discharge from a leprous sore is in- 
oculated. The cause is probably a mixed one : it is a compound especially 
of bad hygiene, exhibited in the bad damp dwellings, the putrid and innu- 
tritions food, and the pernicious action of a malarial climate. There is, and 
always has been, a very wide-spread belief that the fish-eating population is 
peculiarly prpne to the disease. 

IVeatmerU, — This is preventive and curative. I only indicate the princi- 
ples here. We must prevent the inter-marrying of actual lepera ; remove 
them from humid malarial localities ; alter and correct bad modes of living 
in every particular ; secure good exercise and a dry air ; if possible, a change 
of climate. In the actual disease, repeated venesection, counter-irritation 
of the course of the nerves, various baths, arsenic, mercury, canthaiides, <fec., 
have been tried, but with no avail. Hydrocotyle Asiatica, Ginocardia 
odorata, or chaulmoogra (used by Dr. Mouat), the Asclepias gigantea or 
mudar, are looked upon as specifics ; lately Veronica quinquefolia has been 
praised : but all have failed. The local treatment by arsenic is recommended : 
an ointment, gr. x. — xxx. of arsenious acid to | j. of lard is rubbed into a 
patch about six inches large, for a fortnight, so as to produce pustvXation, 
This is often followed by great relief, and the disease is treated bit by bit 
until it disappears — so it is said. I have seen much benefit produced by 
aperients, and subsequently large and continued doses of quinine. 

The leper is an outcast who is thought to deserve no comfort and very 
little attention ; hence the treatment is of the most unsatisfactory kind. 
The whole gist of the latter part of the Leprosy Report is to show the de- 
cided benefit to be derived from the adoption of means to improve the physi- 
cal and moral condition of the leprous poor. There is no cure for leprosy ; 



104 LEFBOim DISEUtt. 

mediL'ine must therefore &iin at its prevention. "It Reems indisputable ^>t 
as tlie agricnlturut and horticultural condition of Britain iLdvanced and tk* 
diet of the working classes was bettered .... lei)ros7 became less com- 
mon," ic. And in refei-ence to India, the committee observe th«t, " with 
its 150,000,000 of inhabitants, the question of the food of the people, in its 
probable relations to the wide-spread prevalence of leprosy and other en- 
demic disorders, is a matter of the highest interest in an econoiuical ns wril 
as in a scientific point of view. That a. marked change in the habtta of tie 
native population will ensue upon the increase of divers industries, the im- 
proved cultivation of the land, the less fre(juent recurrence of famines, uul 
the consequent amelioration of their general condition from year to year; 
and that better food, better clothing, and better housing, with greater itrr- 
sonal cleanliness, will lead to the abatement of leprosy — may be confidentlj 
anticipated." — p. Ixxv. 



X'ffererif/ere of the New Zealanders has been described hy Dr. 
and is clearly elephantiasis. Dr. Thomson's description is briefly as followfe; 
— " It commences with a cutaneous eruption on the extremities, which ex- 
tends over the trunk of the body. The eruption presents in some parta the 
oval patches and the copious exfoliation of a brown scaly morbid cutide ob- 
served in lejira ^^l^garis (?) ; the irregular patches of psoriasis, and occft- 
sionally the innuinerubia fissures, the elongated and extensive cracks inter- 
secting each other, of ichthyosis.'" There is frequently severe pruritus. 
The aspect of the disease is chronic, with a capririuus course ; the hair ia 
gradually lost from the eyebrows, eyelashes, wliiskers, beard — not the head, 
axilli«, nor pubes, however. " The tattoo-murks are not affected." Tiie 
mucous sui-faces suffer, the voice alters, the eye becomes intlamed, th« gen- 
eral surface Uvid ; " the face, nose, lips, forehead, eyebrows, become swoUeit 
and shining; but there arena tubercidar deposits in them;" the aktn ts 
twl aniHsthetic to any degree. In about a year the distal bones of the ex- 
tremities (fingers and toes) are removed one by one by molecular or inters 
stitial absorption ; " a small boil or blister, or dry crack, appears in the 
direction of the flexures .... the soft parts ulcerate by a dry process; 
the phalanx falls off, and the part heals." This is repeated year by year, 
the fingers generally being "dry, shining, and scabby-like." Death ends 
the scene before the wrist is rejiched, by dlairhoea, bronchitis, litc. The 
general health Is not materially affected in the early stages. The disease at- 
tacks people under thirty years of age, generally after twenty ; and the 
great majority (five out of six) are males. It may attack sereml of the 
same bmily. The fingers are affected to a greater degree than tbe toes ; iu 
duration ranges five or six years. From this outline we readily sec tbatj 
disease is true leprosy. 

The Cacuhiiy of Jamaica is probably leprosy. 

Now there are several other diseases in which the main feature is fl 



LEPROUS DISEASES. 165 

posit of fibrinous lymph in the derma and subjacent areolar tissue, either 
separately or both together, and these have some features therefore in com- 
mon with elephantiasis. They however partake, it is believed, more of the 
character of a local hypertrophy of the fibrous tissue of the attacked part, 
and I shall describe them under the head of atrophies and hypertrophies. 
The apparently connecting link between them and elephantiasis will be 
found in morphoea, which I have already noticed as a part of leprosy, but 
will describe more fully in the next chapter as a separate disease. 



CHAPTER XVII. 

HYPERTROPHIC AND ATROPHIC AFFECnONS. 

I NEED not explain the terms hypertrophy and atrophy. Under these terms 
may be included all cases of wasting of normal tissues on the one hand, and 
unusual development on the other, and in the group, hypertrophy and atro- 
phy are primary. Now the forms of disease ranking here are — 

A. Hypertrophic Diseases, — 1. Epithelial, including pityriasis, ichthyosis, 
and xeroderma; hitherto classed with squamous diseases. 2. Papillary: 
warts and the like. 3. Dermic, in which the fibrous tissue of the skin is 
primarily hypertrophied : including scleroderma, keloid, fibroma, bucnemia 
tropica, or elephantiasis arabum, and dermatolysis. 4. Vascular growths, 
such as nsevi. The two diseases, ichthyosis and xeroderma, will be de- 
scribed under the sub-head of Developmental Diseases, at the end of this 
chapter. 

B. Atrcyphic : including general wasting, to which I need not particularly 
allude ; and linear atrophy, which will be incidentally noticed together witb- 
morphoea. 

I only deal then in detail with hy|)ertrophic affections. It will be under- 
stood that no reference is made to secondary or accidental hypertrophy — -— 
the consequence of congestion or inflammatory conditions; but to thos^^ 
diseases in which hypertrophy is the prominent or only condition. 

I. HYPERTROPHY OF THE EPITHELIUM. 

I have been in a difficulty as to placing pityriasis, in which, as a rule^ 
there is simply hyperformation of epithelial scales. I think it best to place? 
it under the head of hypertrophies for the present. 

PITYRIASIS. 

This common form of disease may be discussed in a very few words. It 
is a primary form of disease—'* a superficial cutaneous affection, sometimes 
accompanied by a slight rosy discoloration of the skin, or even a discolora- 
tion of another kind, but always exempt from those alterations of tissue 
which have been observed in the other elementary forms which we have de- 
scribed ; and which scarcely presents any other characteristic phenomenon 
than a desquamation of the epidermis; this latter is detached in small 
whitish lamellae, or falls off in a fine, and, as it is called (from its analogy 
with wheaten flour hvKa— -furfur)^ furfuraceous or branny powder." 

There is no exudation into the skin in ordinary pityriasis. The local 
symptoms are itching and heat. The redness varies much. Authors have 



PITTRt&BIS. 107 

t four main species : P. versicolor, which ia a parasitic disease, and 

II be found undei' the lieatl of tiuea veivicolor, F. rubi-a, P. simplex, and 
F. nigiik. The only varieties we ueed make are P. simplex and P. rubra, 
whicli is on inflammaUiry form. 

I'ifi/riatis gimplcx, accardiug as it occurs in ditfereut situations, lias 
received die n|i|jellations capitis, palpabranio), pudeudalis, oiis, lubialia, 
plitntaris, pilaiis. The history in all these caai-a is the same, a slight itch- 
ing red patch appears, and then white scales form thereon, which are con- 
stantly detacUiHl, BOuietimes a slightly i-ed zone circuuiscrihes the scaly spot ; 
tile scales are toiitiiiuiilly shed and reproduced ; there are no other changes. 
Thu disease is met witli on the bodies of detiitate women and children, 
especially tliti li<wd, whei*? it coustitutcs one of the varieties of '* dandiiff." 
Pitytiasis lutnplex is mostly a disease of early life. 

PityrtOfiU Rubra. — Tlits is a form of diseiuH; in wliicli the skin is acutely 
infliuiied, with free scaliness aud exfoliation of branny lamellar scales, but 
ill which uo " discharge " of any sort occurs. Instead of being local it is 
tisuiJIy gf^neral, aud nH far lus I have seen, the general symptoms are com- 
pamtively slight. Hebin shnll apeak for himself. He gives the characters 
of tbe disease as follows : — '' An intense redness of the entii-e skin, disap- 
pearing on pressure with the fingers, and displaying a yellowish ground ; a 
constant exfoliation of fine, white, loosely attached scales; persistent deep 
ivdness, without infiltration ; papulw, fissures, moisture, or vesicles; scarcely 
any itching, and no excoriation. The diaeaae begiiis suddenly, quickly 
spreads over the whole body, ia rarely local; and undergoes scarcely any 
variation of appearance throughout its course, which may be prolonged for 
ysKTS .... Aft«r death it leaves no trace of its existence lieyond the squa- 
imruM atate of the epidermis. In the eai-ly part of tlio disease the patient 
experiences no inconvenience whatever ht-yond tlie strange ap]>earance ; he 
pursues his ordinary avocations, and believes himself well ; he feels by de- 
^"eea a sense of weakness aud incapacity for exertion ; his appetite fails, his 
muscular power drags ; lie becomes emaciuted, aud finally sinks from ex- 
hauatiou." I have such a case under uiy care now, aud I have seen it in 
children, in whom it produces also thickened plates, as it were, in the skin, 
that feel like a. piece of dried bla^lder, and look yellowish ; it is the derma^ 
titis of I>r. Wilis. There was a possibility of its being syphilitic in some 
cases. In children it lias seemed to nie to be less severe than in adults, and 
to affect a large portion but not tbe whole of the cutaneous surface. It has 
disapiieared iu tlie uoiune of a few weeks in childi-en, under the exhibition 
of tonics, diuretics, and the use of local eniollionts. The distinction between 
{utyri&sis rubra aiid genend jisorioais is by uo means clear in some cases. 
Pityriasis iiigru is merely a patch of pityriaiiis, with pigmentation, and occurs 
]ierhn]iB in those who have visited hot climates. 

A word may be said iu regai'd to one of the local varieties — pityriasis 
pilaris. In this disease the epithelial lining of the hair follicles is the seat 
uf the di&vase, U)d in consequence of the collection of the ihrown-off scales 



168 HYPERTROPHIC AND ATROPHIC AFFECTIONS. 

in the follicles, the latter stand out as it were from the surface like little 
white hard dry knots (something like the surface of a nutmeg-grater), and 
from the summit of each a hair escapes. The knots are produced by an 
excessive collection of ceUs (epidermic), which distend the follicle also, and 
are very adherent. This is apparent on microscopic examination ; of coune 
the follicles are distended, and this is well seen in removing one of the little 
knots. It is seen after pityriasis rubra es|>ecially, and, according to others, 
after psoriasis of pretty general diifusion. According to Divergie, it occurs 
in little ovoid patches on the outer aspect of the forearm, the legs, the bai^s 
of the fingers, and occasionally all parts of the body except the head. There 
is a great resemblance between this disease and lichen scrofulosus of Hebra, 
if not an absolute identity. The reader should refer to the account of that 
vau'iety of lichen. ' 

In cachectic and phthisical subjects pityriasia pilaris sometimes occurs. 
The shedding of the epidermis is due to the general disorder of nutrition. 

The Patlwlogy and Cause, — The seat of the disease is no doubt the de^ 
layer of the epidermis, and the nature of the disease an excess in the cell 
formation of the cuticle. Tliis cell proliferation is an evidence of a some- 
what lower type of vitality, and implies nutritive debility. This may be 
the result of hereditary i)eculiarity, and it is certainly evoked by irritants 
of all kinds acting upon a debilitated system ; in some cases, deficient seba- 
ceous secretion seems to account for the malformation of epidermis. The 
use of strong soap may also be a cause. 

Diagnosis, — This is always easy. There is an entii*e absence of the phe* 
nomena of *' discharge.'' In the simpler cases there is a little redness, and 
scales are formed from the outset of the disease; they are thin, white, 
and shining — branny. Pityriasis may be confounded with (1) JSebar- 
rlicea. The scales ai*e dull white, and dirty : they stick to the surface, and 
are made up of epithelial scales, with a large amount of fatty matter ; 
whilst the sebaceous glands are often distended. (2) Tinea drcinala (pa- 
rasitic) should be known by its circular character, its ** frayed " aspect, its 
clearing in the centre and extension at the edge by quasi- vesiculation, and 
the presence of the parasite detectable by the microscope. (3) Pityriasis 
rubra may imitate eczema and psoriasis ; but it differs from eczema by the 
fact that, though the skin is sharply inflamed, there is no '* discharge," and 
the scales are epithelial and not " blastematous " or ** corpuscular." Thero 
is also little infiltration, no vesicles, pustules, and the like, and little pruri- 
tus. £k;zema, too, in the chronic " scaly " stage, is known by its history, 
and the cracked and uneven Assuring of its infiltratecl surface. I^soriasis 
differs in the fact that the skin is involved to a greater extent than in pity- 
riasis rubra, by the thickening therefore of the derma, the hypertrophy of 
the papillte of the skin, the larger and thicker scales, the cracks and fissures 
that are sometimes present, the well-develoi>ed patches about the knees and 
elbows. In all cases of scaly disease I hold that a microscopic examination 



^.) 



FITTBIAaiS. 



ehoiild bfl made, for by it we determine the eiiitlielial, the fatty (sebori-ha 
or the blaabiniatoua nature (eczema, her|)e8'), etc., of the scalinesa. 

Trealmimt. — In the case of jiityriaais siiii]>l(ix, loc^ nieasiires will often 
suffice. Where there are symptoms uf locftl irritation, rediieet), oiid itching, 
nn ointtneiit nmde at two drachmH of liquor phiuibi, a sci-uple of boi-ax, aud 
an ounce of huxi will suffice. The prioicipul iibject, fts iii so nuuiy other 
affections of the skui, ia to soothe and slightly constriuge. When the dift- 
eam lias become chronic, stimulating applicfttions may be ufMid— the white 
precipitate ointment, the ung. hydr. nitric o-oxyd., or an ointment mtule of 
two dracbius of ung. hydi*. uitratis to an ounce of lard, are serviceable. 
But when the disease is more extensive, and the scalineas free, it is neceEsaiy 
to atlopl general remedies. In this case I use a luiiment of equal pnrta of 
olive oil and Ixme water freely, and wibsequentiy nitric aciil ointment (TUx. 
— mxx. to 5 J- adeps), and commence with tonics — -iron, quinine, nitro-hy- 

Rkloric acid, cod-liver oil, or arsenic, in case there be anaimia, dyspepntt, 
bf deaH, nervous debility, etc. Thei-e must always be perfect cleanli- 
, tliick greiisy hair should be well and rejieatedly washed, the food should 
lie unstimulating, Bpirits and beer avoided if there be any " heating" with 
tliem. The bowels should be made to act regularly and freely. In chronic 
indolent cases, the following will l>e of use : — smraonio-chloride of mercury, 
uul nitric oxide finely powdei'od, of each fifteen grains, olive oil and adeps, 
9a.cix an ounce, with some scent to make the embi-ocation pleasant. Another 
farm empiiicallj successful, is litj. amnion, fort. 3 ij-, ^p. rosmaiini 3 as., gly- 
o«rin>a ^ hs., aqun ^ viij., to be used twice a day, a little borax ointment b»- 
ing used after each application of the lotion. The mineral wat«rs of St. 
Oervais, Aix-la-Chapelle, Pyrenees, Bareges, and Luchon are recommended. 
In pityriaais rubra the treatment hithetlo ado])ted has been found most 
^xnsxtisfactory. In children I have given usually diuretics — calomel gr, ^ to 
H, niCTate of jiotash gr. ilj., and JacoVs fever powder half a gi-ain night and 
■Homing for a fewdaya, alight apeiieuts, then cod-livor oil and quina, with 
aOcaiine and bran baths. Lend and calamine lotion freely applied, without 
&ny irritating application, has seemed to help the cure in the course of a 
few weeks. In adults, matters are ditferent. At this moment, a case is 
under my care at Churing-Ci'oss Hospital, which has been saturat^^d with 
arsenic. The patient took it for two ytars and a half, with calomel during 
n portion of the time. He got muck worse, emaciated, suffered from colic, 
diarrha-R, and sweating, without any relief. With a course of nitric acid 
>it8 health improved, the heat and painful feeling in his skin went, and he 
moved about with comfort ; the redness and the shedding of the scales 
leiaeticd: a course of acetate of jwtash and the use of plenty of grease, and 
dome iodide of potassium ointment, have cei'tainly improved his whole oon- 
ditioB very much. I now purpose to exiiibit phosphorus inteiiially, and to 
employ nitro-muriatic acid hatha two or tliree times a day, and if this fail, 
to give bicyanide of mercury and iodide of jiotash. See Formulw 3*, 80, 
>ft.91. 95. lli.etc. 



170 HYPERTKOPIIIC AND ATROPHIC AFFBCTIONB. 

II. HYPERTROPHY OF THE PAPILLARY LAYER OF THE SKIN. 

Tliere are four diseases which fall under this head ; but thej require very 
brief notice. They are Verrucas or warts, Clavus or corns. Callosities, and 
a state called by Mr. Wilson Pachulosis. In all, the papilla of the skin 
are hypertrophied, often elongated so as to form pendulous tumors, whilst 
the epithelial cells are likewise produced in greater quantity than usual. 

J^emtcce, or warts, are little raised tumors, sessile or pedunculated, hard, 
generally round, rugose, and mammillated. They are made up of coherent 
and enlarged papillte, each containing a loop of blood-vessels, and more or 
less nerve-tissue, especially at their base. I have seen them cover the face 
and present tlie appearance of disseminated lichen. In other cases they 
have been large and in mass. The pedunculated warts, the so-called (tcro- 
chordoiiy are often the emptied sacs of sebaceous glandular enlargements — 
e,g,y moUuscum. The sessile warts, or the true hypertrophous papiliw, 
are seen mostly on the hands in children; they may be multiple, solitary, 
or aggregated in clusters, forming a flat mass or digitate. Warts are often 
tlie i-esult of syphilis about the anus, vulva, penis, but may also arise from 
simple irritation. Yerruca iiecrogenica is the name given by Dr. Wilks 
to the warty growths which occur on the back of the finger-joints of those 
who are much engaged in making post-mortem examinations. *^ They are 
brown circular raised patches of morbid epithelium, giving the appearance 
somewhat of epithelial cancer,'^ and curiously enough, if removed, they 
grow again ; tliey are caused by the acridity of the fluids of the dead body. 
I have seen one or two very cuiious examples of warts. On the little 
finger (at its outside) of a woman, for instance, a mass of warts packed 
closi'ly together, and forming a {vatch If inches long and ^ inch in breadth; 
around the base it was hard, elevated, reddened, something like lupus; it 
might be calleil verrtica granufata^ 

The causes of wart^ are unknown ; they ap|>ear sometimes to be conta- 
gious. The treatment consists in destroying the abnormal growth by 
caustics — the acid nitrate of mercury, caustic |K>tash, arsenical paste, per- 
chloride of iron, or chromic acid ; the best is potassa fusa. 

CoTM are simply a like comlition to warts, only tliat the epithelium is 
|H^uliarly atfiH^ttHl : they are brought about by pressure and friction ; they 
are of thixv kinds — laminated (tylosis), fibrous (clavus), and soft coma. — - 
(Wilson.) The lamiiiatetl are the ordinar}* ; the fibrous, the well-marked, 
old-standing c\>ms ; the s^>ft ixxnir bi^tween the toes, and being saturated 
with tlie stvretiou of the part, are moist and s«.>ft : generally there is some 
senvdty etfusiHl under the upjH'r layers, and this is discharged from a little 
central a^n^rture. Mr. Wils^ui gives the name of j«chulasis to the thick- 
ened state of skin which follo^*s the healing in elderly i»ei»ple of ulcers of 
theh^gs; the skin is harslu thick, and di-jM^to, The tneatment of these 
minor atTtvtious utHnl not U» detaiUnL The i^apillse of the skin may some- 
times enlarge j>o e^Ltonsivoly as to pixnluce horns — iliis is uncommon, how- 



HYPERTBOPHIC DISEASES OF THE DERMA. 171 

ever. Horns are usually sebaceous in origin. Mr. Edwards says that the 
microscopical appearances denote them to be an hypertrophied condition of 
the papilltt, each containing one or more vessels and being covered by epi- 
dermis ; on section they have a '* granular texture pierced with small ori- 
fices, and when dry, numerous concentric cracks." The orifices, on further 
inquiry, are found to be the sections of little blood-vessels; "a clear 
amber-colored circular area surrounded each of the vessels, which were 
separated by the general granular structure of the mass, incapable in the 
compact part of the horn of being reduced to its ultimate original elements." 
The structure appears to be best seen at the edge of the horn, where ** the 
vessels are seen occup3ring the axis of the papillse, which are indicated by 
the clear cylinder area surrounding the vessels, the limit of the clear cyl- 
inder appearing to be the basement-membrane of the papillse, and pre- 
senting on an oblique section a somewhat jagged outline. The central parts 
of the horn are more compact and less vascular than the outside." 

I have seen several cases in which the individual papillsa of the skin, 
especially in the face, have become enlarged, their vascular part being in- 
volved, yet not sufficiently (in excess) to make the disease neevus ; it was a 
general equable hypertrophy of the structures composing the papilla?. Con- 
dylomata are hypertrophied papilles moistened by secretion, and containing 
rather more fibrous and elastic tissue than usual. Formulas will be found 
for caustic applications elsewhere. 

Callosities are merely hardened conditions of the skin produced by pres- 
sure, difiering from corns rather in the fact that they are on a larger scale 
than anything else. I have seen them very large and hard on the front of 
both shins : blistering and iodine paint caused their absorption. 

We come now to 

III. HYPERTROPHIC DISEASES OF THE DERMA. 

Under this head are included all those diseases in which the fibrous tissue 
of the skill is in excess, and in which the disease extends to or involves the 
subjacent cellular tissue. They are (1) morphoea ; (2) scleroderma; (3) 
keloid; (4) fibroma; (5) bucnemia tropica; and (6) dermatolysis. My 
reason for placing morphoea in the gi'oup has been given. I repeat that it 
occurs in connection with veritable fibrous hypertrophy of the derma. 

MORPH(EA. 

This disease sometimes complicates anaesthetic leprosy, but may exist as 
a separate disease. It involves the whole thickness of the skin in all its 
parts. The disease occurs in non-elevated patches, in size from half-a-crown 
to several inches, which, originally red, quickly becomes white, hard, dense, 
and aniBsthetic in the centre. They are often edged round with a network 
of vessels in the form of a lilac ring. The disease is caused by a deposit in 
the skin of a substance like lard, which presses on and obliterates the ves- 



t4™ BTPBBIXOPHIO ANO ATBOEBtO ATFSOTIQMB. 

boIb, hairs, glamlx, and uervea. Wh-en it is very white it is called marphiea 
^ba; sometimes pigment Is deposited, and tlien we bave morjilid-a ntgn. 
The wkiteaeas is, however, generally very decided ; the )>atche» loi>k wasy, 
or like alabaster. Though there is uo elevation, the Kkin ia evidently thick- 
ened by the dense white deposit. The de]x>sit is followed by coUBidevable 
condensation. The epidermis ia hoLiiy and sometimes yellowish, mrely dia- 
quaniatiug. Once ncen, the disease is never forgott«n. In some cases the 
deposit of material is not so marked as in others, but there is atrophy to- 
gether with condensation ; a till, however, the erythematous circle. This ts 
called morjilnr.a atrophica. The akia is not poUshed, but white, diy, 
shrunken, parchment-like, umesthetic, haii-lcss. This variety is soioi abuut 
the neck and the inner side uf the legs. When it occurs in bands or lines it 
constitutes the "linear atrophy" of authors, which is seen about the fore- 
head, onuB, legs, or even body. Of twenty-five cases collected by WiUon, 
"ten were atrophic, seven tuberous, 6ve mixed, three melasmie ; " eleven 
were unilateral, fourteen bilateral; tlie trunk of the body was atfect«d Id 
«]even, the legs and thighs in seven, the arms in six, and the submammaiy 
region in three. When it occin-s on the forehead it takes the course of the 
Hupm-orbital nerve. In the last cast) I saw, se]iarate grooves, tlie one ia 
which I could lodge my little tioger, the other a piece of ordinary stick 
pencil an inch long, were formed ; the edges of the spots were red, tii« oeo- 
tres sunken, white, dense, and insensible. 

T/te nature (if tin) diaettm is cleai'ly a retrogi-ode metamorphosis of tlie 
texture of the skin ; a fibi-o-cellular degeneration. Where the deposit is 
well marked it might bo called lardaoeous disease. Morphcca occurs in el«- 
pbantinsis, but also as a separate disease, and in connection vath sclerodernuk 
In some cases it is found to be associated with fibrous hypertrophy of tfao 
skin, taking the form of large bands or masses, and this Bssociat«d form <nu 
clearly what Addison described as keloid. An examination uf the models 
in Guy's Hospital has satistieil me on this point. In morphiea there is no 
elevation. We now come, however, to ^ disease in which the Itbroua dA> 
posit produces distinct elevation — ^-iz., 

BCLERIABIS, OR SCLERODERMA. 

In some ctuxa it is associated with the morphiea I have just described, 
and in others it exiuts alone aa a 6e|iarnte disease. We iind extensive de- 
posit in the skin in bands or lineH, with condensation, and subsequent con- 
traction. This scleroderma is also called " bide-bound " disease. The hard- 
ness and stilTnesa may come on suddenly over a large extent of surfaoe — 
from groin to knee, for instance. The disease generally commences by an 
induration or homy plate, and 8ubae<|uently spreads in the form of btuids ; 
these are raised, dense, often yellowish in the centre, fading away through a 
white color at the borders, into the hue of the surrounding skin. Tain ma,y 
accompany tliis stage. Them may be a partial border of vessels at the oaU 
Bide : much distortion of contiguous parts, wi^ puckering of the tiwi^ 



8CLEBIA8I8, OB SCLERODERMA. 173 

results from the contractile nature of the deposit ; this is very well marked 
about the &ce and joints. The sensation of parts is impaired. The disease 
affects seveitd parts of the body successively. After a while the skin 
becomes hard, shrivelled, parchment-like, the sensibility being distinctly 
diminished. The disease is more frequent in the female than the male, in 
thirty-seven out of forty recorded cases ; it may attack infants, especially 
about the hips, thighs, back, buttocks, and elbows. In adult« it occui*s at a 
tolerably early age. A very good description of a case runs thus in the 
Ijancet, 1855, vol. i. p. 239 : — 

** The induration and cicatrix-looking condition of the left arm and fore- 
arm peculiar to the dLsease. Tlie appearance is not that of a tumor, but 
rather as if the arm had been burnt, and had left a leather-like hardness, 
^hich required surgical operation, as after a bum, to remove it ; or it seems 
as if a bad erysipelas had become turned into cartilage and bone." 

Morbid Anatomy. — More information is needed on this point. 

The following is a description of a case given by Forster, and quoted by 
Fagge: — 

** The affected paiis are described as being of a yellowish or brownish 
color. The thickness of the skin was at least 3'" over the sternum and the 
clavicles, 1 — IJ"' on the abdomen, and 2 — 3'" on the anterior surfaces of 
the thighs, legs, and feet. 

" The state of the skin was essentially the same in all the affected parts. 
It could not be raised into folds, and was not in the least degree movable 
on the subjacent parts. It could be cut only with great difficulty, being in 
fact almost as hard as the sole of a boot. On the cut surface the first thing 
observable was that the distinction between corium and subjacent tissue 
seemed to be obliterated, a homogeneous, white, shining surface presenting 
itself On closer examination, however, an upper layer of more unifonn 
texture could be distinguished from a lower stratum, in which the fibres 
were arranged in meshes. It might have been supposed that the subcutane- 
ous tissue had entirely disappeared, but investigation showed that, besides 
the proliferation of the connective tissue of the corium itself, the areolar 
stratum beneath also had imdergone a similar process by which it was con- 
verted into a substance resembling corium. The fat, however, had really 
completely vanished, a few rows of fat cells only being seen here and there 
in the microscopic sections. The elastic fibres seemed to have multiplied 
in the same ratio as those of the connective tissue, for they wei*e present in 
due proportion. Except in the cicatrices, the papillae were normal ; the 
cutaneous glands and hairs were unaltered, but seemed decidedly fewer 
than usual. The capillaries appeared not to have increased with the tissue 
in which they lay, but on the contraiy, to be fewer than natural ; but they 
had not undergone any morbid changes. Veiy few nerves were seen, but it 
is probable that they were merely hidden by the increase in the connective 
tissue. The insensibility of the affected parts during life was most likely 
due to the nerves being so closely enveloped in this substance, for when the 



174 HYPERTROPHIC AND ATROPHIC AFFECTIONS. 

thickening had subsided at any spot, the sensibility had returned. The 
sclerosed connective tissue was firmly bound to the muscles, fascia, and ten- 
dons, the normal loose intervening tissue being entirely absent. '^ 

Recently Dr. Kasmussen has written an admirable essay upon the sub- 
ject, and in the post-mortem of one case affecting the chest he found the 
epidermis thick, and beneath it a dense whitish fibrous substance, extending 
down in some places to the ribs ; the glandular tissue of the left breast and 
some of the intercostal muscles were replaced by fibrous tissue. The pleura 
costalis opposite the locality of the changed skin, the diaphragm, and the 
cai)sule of the liver, were indurated in little tubercular masses. On micro- 
scopic examination, the epidermis was found to be of the ordinary thickness, 
the papillw normal, the corium rather broader than normal, the connective 
tissue below much hypertrophied, and studded with spindle-shaped cells; 
the small arteries were surrounded by closely aggregated ceUs, like lymph 
corpuscles ; the peripheral oblong, the outeimost spindle-shaped and separa- 
ted by a homogeneous or slightly fibrillating membrane. Indeed, the vessels 
were ensheathed in this lymphatic tissue. The hair ducts and nerves ap- 
}>eared to be unchanged. It is clear that the seat of the disease is the con- 
nective tissue and the corium. The disease, too, is an hyperplasia of the 
areolar tissue, invading the normal structures, and gradually obliterating 
them — ex., papillfe, nerves, vessels, hair-sacs, etc. 

But what is the origin of the hy}>erplasia ? Easmussen thinks the dis- 
ease commences by infilti-ation from the lymphatic vessels (lymphatic cedema 
of Virchow) into the coimective tissue, the hardness being produced by the 
fi*ee development of cells in the fluid effused. This second stage, he thinks, 
is the only one genemlly mentioned, the first, or erysipelatous inflammation 
of the lymphatics, being overlooketi. 

Rasmussen declares that the changes in scleroderma are the same in kind 
as those seen in the bucnemia tn>pica, or elephantiasis arabum, and he 
thinks the seat of the disease is in the lymphatic system. The small arteries 
are sum>uudixl by a sheath of lymphatic vessels, which furnish the lymph 
out of which cells aiv formeil in the otnmective tissue at a veiy prodigious 
rate. He has acoonlingly pro^Ktsed to call the disease elephantiasis sclerosa. 

But what of the relation of ** morphiva,'^ which is common apparently to 
true lepnvsy and to scleroderma ? Is it simply htr^iacfoui disease ? Is it 
that the dejtosit affects es|HH.*ially the nerves, and sensibility goes as a oon- 
sei|uence ; or is it that the de|H>sit is the cous(H|ueuce of d'sorder primarily 
in the nerves ? I incline to the former of these two opinions. 

The cause of solervxierma is not understood. 

The Dia*/>um4 offers no difficulty ; the indurated, hard, tense, contractile 
bands are sufficient Iv distinct. 

It is certain that tlie moqthiva may be the early sta^ of sclerodemuL 

Trtaim^Hi is not promising. The op|H>rtuuities of seeing scleroderma 
arv so few that no definite principle of trv«ituient is laid down. The pn»- 
(tarations of iodine with iron, cod-liver oil, nitric add in large doses^ dumge 



BHIN08CLER0MA. 175 

of air, chalybeate baths, and inunction with black oxide of copper, gr. ij. ad 
§ j. (Rasmussen), are those most usually employed. 

In regard to morphoea, tonics, especially the mineral acids and iron, by 
improving the health, help its removal, and a^ the general condition im- 
proves so does the local. 

Exception may be taken to the position which I have assigned to mor- 
phoea and scleroderma, but I regard it as a tentative one for the present. 

RHINOSCLEROMA.'*' 

Hebra has described in the Wiener Mediziniacfie Wochenscrifty January, 
1870, a peculiar new formation about the nose, which he has named Bhi; 
noscleroma. He says : — I have had occasion, in the course of several years, 
to observe a skin disease in nine individuals (four men, five women), which, 
by having its seat either on the nose or in its immediate vicinity, as also by 
the peculiarity of its phenomena, presented itself as a malady sui generis. 
To form an idea of it, a substantial syphilitic sclerosis of the prepuce, in 
optima formay may in imagination be transplanted to the external nasal 
structures, in one case even to the alse nasi, and in another to the nasal 
ridge ; to the mucous surfaces which form the borders of the nasal cavity ; 
or lastly to the skin of the parts sun-ounding the nose, as the upper lip, 
skin, forehead. Among the nine observed cases there were only two which 
presented the disease on the nose, cheek, and forehead simultaneously ; in 
the others it was confined to the nose and upper lip alone. As a fiat swell- 
ing, it projected as much as 1^ lines in some places, its extent being always 
limited by a sharp border, with steep edges. The color of this new forma- 
tion varied from normal skin color to a dark reddish brown. The upper 
surface of the diseased places was always smooth, rarely shining. The most 
striking objective symptom consisted in the extraordinarily complete indu- 
ration of the affected places, which had an almost ivory-like feel. Besides 
this, the patients experienced but little pain, and usually only when the 
formation presented itself localized on the inner surfaces of the nose, and 
when these prominences were pressed. 

In all cases the development progressed very slowly, requiring sevei*al 
years before the trouble had acquired dimensions which obliged the patient 
to seek medical aid. 

The impression made upon me by the first case I saw, was that of a syphi- 
Htic disease, as the brownish-red, pea-like elevations had localized themselves 
partly on the upper lip, partly on the inner surface of the alsa nasi and sep- 
tum, after the manner of a circumscribed tubercular syphilide, and only 
differed from the ordinaiy characteristics of that affection by the unusual 
hardness of the morbid production. It chanced that soon after, during 
treatment of the first, a second case was admitted to my division in the 
General Hospital, which, besides the hard tubercle of new formation on the 

* Vtam tfae Amezican Journal of Syphilography and Dermatology, April, 1870. , 



176 IIYPEBTEOPHIC AND ATROPHIC AFFECTIONS. 

nose, alno presented all the pathognomonic symptoms of an acute specific 
iil(;<?rative angina, so that I was only the more confirmed in my opinion, and 
looktMl upon the malady as the result of syphilis. The treatment by inunc- 
tion was now introduced in both cases, with the daily administration of two 
pints of Zittniann^s decoction, with the local application of emplastrum 
liydrargyri to the hard jirotiiberances on the nose and upper lip, a treatment 
by which, if, however, sometimes only temporarily, syphilitic products are 
always induced to undergo retrograde metamoq)hosis. But in the cases 
UKMitioned, this treatment was entirely insufficient ; for although the pha- 
ryngeal ulcc^rations of the second patient healed and cicatrized in the usual 
manner, the exttnit and induration remained undiminished. A similar in- 
effectual result was ex|)erienced from a continued treatment with iodine, so 
that my opinion of a syphilitic origin of the malady wavered. It was, how- 
ever, more shaken by further observation of cases. Thus, the third case 
was that of the mother of a royal officer of high rank, an elderly lady, who 
liful sutf(M*ed from this malady for many years, and had been treated at dif- 
f(»r(int plact^H and times and in manifold ways by other physicians, — with 
mercury, iodine, arsenic, and nevertheless pi*esented a slightly enlarged nose, 
of thf) hardness of ivory, and of a bluish-red color. The fourth and fifth 
oiM(»H again occurred in men, with the same symptoms, course, and similar 
olwtiiuicy to all medical treatment. On the upj)er lip there were several 
tulK'roloH {tartly crowded together, and partly connected, having the sijse of 
IHUiH and the hardness of ivory, from which a portion was removed to ex- 
amine their structure microscopically. At the same time in this case, the 
whole of the lofl nostril, skin, and cartilage had the ivory hardness, and 
wna distortiHl upwards and outwards, not, however, differing in color 
fnuu the health v skin. 

The most iHNUitiful and instructive cases of this rare disease are, however, 
thoM* which at the pn^sinit time are under my observation. Two of them 
pn'sent the tuln'rculous indurations principally on the nose, especially on 
the inner sxirfact^ of the ala» nasi — in one female {latient a tubercle is alao 
MituatiHl on the out4*r surface of the right half of the nose; the third female 
|>ationt, however, not only presi^nts a completely indurated nose of a dark- 
mhI oidor, but aliH> thnn* ivory-like |»ale-red protuberances surrounding it 
IVo of thoM* an» situateil, one on either side of the nose, extending from 
the inner iitnthus to the up|H»r lijt — which r?raains intact — and not only 
<H>mplotoly till the dopn^on betwe<»n the side of the nose and the cheeks, 
but «ls«> tnorlap with their ]Uirticularly hard sharply-maigined edges, the 
sui'fa^'^^ ci>vonng the zygiunatio arch, from whence they slant towards the 
M*>m\ Hie thinl pri^tuWramv is situattnl on the os finontis, has a length rf 
one and a half indues, and m-idth of a half inch, and extends from one eycM 
to I he other; it is Mmilar in oi^^lor to the normal skin, and aomewbat loB 
indurMt<Hl than the two lateral om^ but pressure on the eyelids pieveoti 
their oj^oning. 

When 1 WW this la»t-mentione«i c*s»e, 1 recollected having seen a uBiilar 



BHINOSCLEBOMA. 177 

one in Paiis in the year 1852, in an elderly lady. As I did not visit the 
lady as a physician, but was only introduced to her as a guest, I could make 
no inquiries concerning her history or the physicitins who attended her, in 
order to consult with them about this, at that time, to me, puzzling disorder. 
I afterwai'ds ascertained that her attendant was a homoeopath, a })owerful 
invasion against the malady had, therefore, not been instituted, and that the 
trouble remained tn statu q^io up to her death. 

After having given a sketch of the cases observed up to the present time, 
we find the following characteristics common to all : — 

1. In their constant seat on the nose, and sometimes also in its immediate 
vicinity. 

2. In the extraordinary induration of the affected parts. 

3. In the exceedingly slow development of the pathological product, which 
appeara either in the foim of dai*k, brownish-red tubercles or knuckles, or 
as induration of the normal appearing tissue. 

4. In the sharp margination of these indurations, and the absence of all 
oedema or inflammatory symptoms in the vicinity. 

5. In the absence of all apparent metamorphosis of the new formation, as 
it neither degenerates, ulcei*ates, softens, nor is al>sorbed. 

G. In the failure of all internal treatment, even with the strongest 
agents. 

7. In the absence of all danger to the system at large, even in case of its 
existence for many years. 

8. Lastly, in the insensibility and painlessness, when the diseased pai*ts 
are left untouched, severe pain on the contrary, when the dark i-ed tubercles 
are pressed. 

As the localization of the trouble in the face in eight out of the nine cases 
rendered it impracticable to remove even small particles of the new forma- 
tion with scissors, we had to defer the microscopical examination until the 
acquisition of an appropriate case. 

When, at length, such an one presented itself, the apex of the isolated 
tubercle was removed, and carefully examined by my assistant. Dr. Moiiz 
Kohn ; he found the epidermis and the layer of the rete Malpighii of nor- 
mal appearance. Between the elements of the latter especially there were 
no abnormal occuirences. 

The papillffi were somewhat longer than usual, conical or knobby ; their 
external connective-tissue structure markedly wasted ; the connective tissue 
of their body only present as a network of delicate fibres and small inter- 
vals ; their blood-vessels scarce and thin. The connective tissue of the vas- 
cular stratum also present only as a pale, thin, delicate network of fibres. 
This network of the vascular layer and of the papillae was filled with small 
cells, crowded closely together, and the infiltration of cells, at different 
places extended down deep into the corium, was, however, found regular, 
and close only in the vascular sti'atum and in the papillie, which latter es- 
pecially appeared stuffed with cells. Tlie cells wei-e smaller, esjieciallv in 
IS 



I 178 HTrEsmoPHio and atrophic ATFsoncms. 

the piHitopliuEna, titan the grauulation-cells as a nile are, aa ve met^t them 
in acutely or chronically iullanieil tistiues, and iii places where the form&tion 
of new connective tissue is in progresf. The nuclei of the cells were small, 
little refractive, and finely gi-auulated. 

The cells appeared Kimply stored away in the delicate connective-ti««ue 
Htructure of the papillffi, and the upper layers of the corium, and by a^t»- 
tion were eosily displaced. 

The deeper layera of the corium showed a close coonective- tissue arrange- 
meat, which had rauiaiDed more fi'ee from the described formative irlemeuts. 
The layer of fat-cells normal. Only sjiare cells in the fibres of the t-'onnec- 
tive tissue net here present, and there ]u-incipally in the \ieiiiity of the 
vessels. 

Sebaceous and sudoriferous glands could not be found in the sections ex- 
amined. The huir-bulbs, external and inner root-sheath of the hair, were 
free from all foreign formative elements, while the papilla* bordering on the 
hair follicle appealed crowded full of the above-deaci-ibed cells. 

The above-described sclerosis of the skin is, therefore, by this explaiM- 
tion a cell-iniiltnition of the upper Layei-s of the corium and the whole [wpil- 
lary body. The normal sti'ucture of the aifect«d tissues has thus far suf- 
fered by the massively accumulated new formative elements, so that the 
connective-tisbTie structure of the papillte, and of the upper part of tlie 
corium, is forcibly separated and crowded out, and ita elements are m- 
newed. 

The cells of the new formation nowhere exhibited that pale, dusted (fiue- 
ly gi-anulated), indistinctly nucleated, not shari)ly contoui-ed a|>i<eanuioe 
(so-called degenei'stiou) of the cells ui syphilis and lujius ; but they ajt- 
l>eared well pi-eserved, with sharp contour and distinct nucleus, and imbibed 
camiine well. 

We believe, on the strength of the above microscopical charactei-s, which 
certainly made the clinical facts in the character and coiii'se of the new for- 
mation intelligible, though only imperfectly explainable, that this rhino- 
Bclei'onu) may lie placed histologically next to the glio-sarcoma or gi-nuulation- 
sarconia iVii-chow, Billrotli). 

In conclusion, I may be allowed to state something I'egardlng tniatnieiit, 
Jiitheirto of but little avsil. In two cases, where the tubei-cles jircgected 
.from the inucr surfacis of the nostrils into the nasal cavity, and elTectu^lf 
prevented the ingress of aJr, I have destroyed the tubercles with CKOStic 
potaasa iu substance, and after se{)aration of the slough, have produotid 
cioatrization by a frequent coating with concentrated solution of uitr^te 
silver (aa. p. aeq.). Compressed sponge introduced was effectual in- 1 
venting •con traction of the cicatiix, and thus the perviousness of the 1 
entrance, and the [losaibility of uuimjieded ingress and egress of air^l 
miuutained. It is of im|)ortance to ob^terve that after destnictioo a 
new formation with caustic potassa no i-egenei-utiun tuuk place, aa I 
obsen'ed in other ibrmutions, as for instance, ejiitlielionia, aud also tl 



KELI8 AND KELOID. 179 

neighboring morbid product was neither disposed by the induced action to 
retrograde metamorphoslB, nor to more rapid development. 

KELIS AND KELOID. 

There is another hypertrophic growth of the fibrous tissue of the surface 
having a close resemblance to scleroderma, and called kelis or keloid. The 
kelis of Addison is the morphoea I have described. The difference between 
keloid (as I shall continue to call it) and scleroderma consists in the fact 
that in keloid the corium, and not the cutaneous areolar tissue, is the seat 
of the disease, the hypertrophy forms a distinct circumscribed raised tumor ; 
the disease is more limited, and it is more vascular. It was described by 
Alibert as cancroide. It is not cancerous ; it is rare ; does not ulcerate ; 
does not implicate the glands ; and is not destructive to life. The name 
keloid was given to it from the resemblance of offshoots to the claws of a 
crab. It is characterized by the occurrence at first of flattened swellings, 
generally oval in shape, palish, or deep rose in color, and shining ; the cen- 
tral parts generally become depressed, and processes (claw-like) run away 
from the edge of the patch into the surrounding part. Sometimes at otiier 
parts small, flat, pale, red, or sand colored elevations, the size of split-peas, 
or a small nut, make their appearance. It is usual to describe two forms — 
the keloid of cicatrices, or &lse keloid, developed in old scars, bums, wounds, 
etc., and the true keloid, or kelis, a form of disease which is primary, and 
very frequently possesses many distinct localities of disease (it is desciibed 
above). It is often seen on the chest. The false or spurious keloid — viz., 
that which follows scars — ex., those of bums, scalds, rupia, boils, or even 
the use of acids, is the conunoner variety. 

The keloid of cicatrices usually begins as ** very hard, small, shining, tubercu- 
lar-looking elevations, of a roundish or oval shape, somewhat firmly set, of a 
dusky or deep red color, and generally attended with itching and pricking, 
shooting or dragging pain in the part," which is the seat of a scar. These 
tubercles increase in size and grow pale, flatten out and become depressed 
in their centre, which is marked by white traversing lines or bands, and a 
few straggling vessels. The increase takes place by means of oflshooting 
lines, which run away from the edge of the tumor, claw-like processes ; 
they are ^^ to 1 line broad by 1^ to 1 inch long ; the growth is slow, and 
may affect the whole area of the bum or scald, the site of which, in fact, 
becomes hard, leathery, and raised. 

Dr. Longmore describes it thus, in a case which occurred after flogging : 
— A small round tubercle, which became a flat mass utfarly as large as a 
man's hand, without pain; there was some initability, and it was tender 
-where pressed upon by the cross-belt and the weight of the knaj^sack : on 
the front of the chest several small tumors, evidently of the same nature, 
were observed. So that we get in this form a rcrsult which is admirably 
described in a ease of keloid following a bum, under Mr. Curling^s care, as 
follows : — ** The whole has assumed a keloid state ; it is thick, bossy, indu- 



180 HYPERTROPHIC AND ATROPHIC AFFECTIONS. 

rated, looking remai^kably as if very luxuriant and elevated granulations bad 
healed over, and then, instead of shrinking, had undergone consolidation 
and some increase." As Mr. Wilson has it, " false kelis appears to be the 
joint res\ilt of hypertrophy, condensation, and concentration of tlie white 
fibrous tissue of the skin, and by a si)ecial power of contraction would seem 
to draw the rest of the cicatrix to itself, and produce a puckering of the 
adjacent surface." In fact, the keloid of cicatrices is but the hypertrophied 
fibrous tissue of the scar. 

3Iorhid Anatomy, — Keloid is merely hypertrophy of the white fibrous 
tissue of corium. The gi-owth is made up of closely-packed fibres with 
many nuclei, but few vessels. The fibres of the areolar tissue do not '* con- 
stitute curly bundles but thick trunks, the firmly compressed fibres of which 
run at first in an almost stimght direction, gi*adually separate from one an- 
other, and finally fall into several distinct bundles, which, vibrating in curls^ 
after i-epeated subdivisions, are at last in nothing distinguishable from nor- 
mal ai*eolar tissue : " the ti-unks are closely compressed and interlace. '* The 
tumor is supposed to be formed by a few vessels |)assing through a capsiile of 
areolar tissue, supplying the plasma from which the fibres are develo|>ed.^^ 
(Dr. Benjamin.) 

Diagnosis, — The elevated tuberculous tumor, with the claw-like processes, 
the puckered state of the skin, the absence of ill-health, of glandular enlarge- 
ment and ulceration, are diagnostic. The false keloid of cicatrices and true 
keloid, or kelis, only diifer in the fact that one is idiopathic and the other 
secondary to cicatrization following lesions of the skin. Some observers 
have noticed yellowish }>oints at the apices of the tubercles — a commcuciug 
fatty change. 

The Treatment of keloid consists in improving the general health, and 
then a coui-se of liquor potasso*, or the iodide of ammonium or arsenic. 
Locally, the use of steady and continued i)ressure, iodine fiictions, the pas- 
sage of clectiic currents through the tumor, and iodide of load ointment. 
It is useless to remove the tumor by caustics or the knife ; the less inter- 
ference the better. 

BUCNEMIA TROPICA. 

Elephantiasis, as I have befora noted, in its widest signification, includes 
two very different diseases ; the one E. Ai'abum or Arabica, or Barbadoes 
leg, properly Bucnemia tropica ; the other E. Gnecorum, the true tul>er- 
cular and amesthetic leprosy. Tlie fonner (bucnemia) is essentially a hyi">er- 
trophy of the cellular structures : it attacks the lower limb particularly , and 
is said to have no relation to true leprosy. 

bucnemia tropica^ Spargosisy or Sarbadoes leg^ probably sporadic every- 
where, as its name expresses, is common at Barbadoes ; and es|>ecial1y iu 
Cochin China, West Indies, Eg3rpt, ]Malabar, some pai-ts of Soutli America^ 
Abyssinia, and tlie Polynesian Islands. Tlie disease usually attacks the 
legs, and is mostly confined to one ; but it may afiect the face, neck, bellvy 



BUCNEMIA TROPICA. 181 

breast, pudendum, the arms, and scrotum — in Egypt it is called sarcocele. 
It lasts a vaiiable time, possibly a lifetime ; attacks all classes, and is non- 
contagious. It is marked, when fully developed, by three features: — (1) 
Hypertropliic growth of the cellular tissue ; (2) alteration in the aspect of 
the skin ; (3) more or less defoimity. And these are brought about as the 
result of intermitting and repeated attacks of inflammation of the lymphatics. 
In well-marked cases the disease is ushered in by distinct febrile symptoms, 
vomiting and headache at times, and locally, redness, pain, and tension over 
the course of the lymphatics, which presently feel knotty and corded ; the 
glands are swollen and tender. The constitutional symptoms soon vanish — 
in a few days ; but the b'mb does not resume its natural size ; the glands 
especially remain enlarged. A rei>otition of fever occurs at uncertain inter- 
vals, and after each attack the enlargement is penoanently greater ; and it 
has been ascertained, from careful observation, that the size of the affected 
part bears a direct relation to the frequency of the acute attacks of fever 
and local inflammation. The pain, in the first febrile attack severe, is slight 
in subsequent ones. During the progress of the disease, deposit and thick- 
ening have been going on in the skin and subcutaneous tissue — hence the 
sensibility of the part is somewhat lowered ; but, unlike that, in the true 
form of elephantiasis, is never annihilated, nor indeed seriously lessened. 
The swelling in the disease may be pretty uniform or partial ; sometimes it 
is enormous, as when the disease attacks the scrotum ; then it has been 
known to produce a pendulous tumor of sixty pounds weight. Tlie skin 
undergoes distinct change ; it is tawny, hard, dark, livid, thickened ; often 
scaly and fissured or grayish ; presenting warty projections, especially about 
the joints ; the veins are varicose, the surface then closely resembles the 
skin of an elephant. The subsequent changes are ulceration, with sprouting 
granulations (fungous), suppuration, and foul discharge. The glands par- 
ticipate in this action* The disease may carry off the patient by hectic. 
Frequently its progress becomes stationary, and the patient gets aboiit as 
best he can with his unsightly defoimity. The palms of the hands and the 
soles of the feet generally escape. In this country a similar condition fol- 
lows chronic ulcers of the leg ; the limb enlarges, and its fibrous element 
hypertrophies so that it is nearly twice its usual size. The average size of 
340 cases, round the ankle, Mr. Waring found 11 ^\ inches. Here are the 
particulars of a scrotal tumor removed successfully by Dr. Thebaud. It 
reached to within five inches of the ground ; it was 28 inches long, 20 inches 
in its bilateral diameter, its widest ciix;iimference 48 inches ; and it weighed 
63^ lbs. when removed, and the opening of the penis was 18 inches from the 
surface. 

The Pathology of the disease appears to be well made out. It is, as 
shown by actual observation, a hyijei-trophy of the derma and subcutaneous 
tissue, with the effusion of a blastema, of homogeneous aspect, mixed up 
with a large number of molecules, gi'anules, free nuclei, and nucleated cells. 
The epidermis is more or less affected — thickened ; but this varies in many 



182 BYPEBTBOPmO AWD A1S0PBI0 ATFBCTIOSB. 

canfM. Ttie cutut is thiclcened, the ])a|>ill)tr are distinct and promiticiiit, xim 
BDbcutttnoous cellular tiiwue (areolur, fatty, and elastic elements) u p(«*eiit 
is excess, and infiltrated hy the blustema just spoken oE. The veitis mre 
distended, the lymphatics oblil«roted ; the muscles often pale aiid fktty. 
The intenml organs also arc &e((u«ntly in a st«te of fattv degenentiou. Hms 
bloslenia, whon firat effused, ia slightly milky, and contains albnueu, khdc 
fibi'ine, etc. The primary seat of the disease is the blood ; tocaUjf thn tyro, 
pliatics are primarily affected. 

C'liu'w. — The disease is not herettitttry, and not contsgiuns. It atlacki 
tnoles more tliiiu females ; according to Mr. Waring's oliservatiotis 7i pen 
cent, of cases were males and 25 females. It is most frequent between ihe 
ages of twenty-five and fifty. Of 945 cases collected by Mr. Waring, 729 
occurred in people wh<Me ages ranged between twenty-six and sixty; 139 
between five and twenty-five; and 77 after the age of sixty. In bHi per 
cent, true lejirosy is conjoined. 

The date of its first a|ij)earance is noted alao: existing ainoe chilclhocd 
in 16 cases; apjieuriog before the fifth year, 7 cases; between six and t«u, 
33 cases; between eleven and £fteen, III cases; between sixteen and 
twenty, 223 cases. As to the part aJTected, it was the riglit leg alone, or 
with other parts, in 307 cases, or 33 per cent. ; the leg alone, or with other 
parts, in 387, or 30 jier cent.; both Umbe, &c., Sii, or 3li [>er cent. ; other 
pai-ta alone iu seven cases; the upper limb in four cases. This agreea with 
Mr. Day's resesj'ches iu Cochin China. He found that the disease attacked 
the lower limb in 03 jier cent. In 224 out of 22G cases in which the point 
was examine^, Mr. Waring found the febrile attack primary. Eurojieans 
are less liable tliau natives to be alfecteil. Among the causes, hot cUmaU 
and malarial emanntious are sup|)osed to have some influence. Hr. Warii^ 
tliinks that the chai'act4>r of the water used by the inhabitant>4 has mudi 
to do with the disease: "the sea-water, penetrating through tlie porous 
saud, renders the wslei' saltish and brackish, and as the genei-ality of ihete 
[>ools are surrounded by trees, it in addition soon becomes loaded witli d««d 
Vegetable matter, which undergoing decora jiosition, renders the water 
(almost black) and h^hly offensive to the taste and smell, which i 
ing and filtering fail to deprive of its unwholesomeuess." 

Prtiirnotu. — The disease is chronic. Mr. Waring found, in 218 > 
llie duration of the disetiBe i-ange between twenty-six and fifty-fiv 
If the disease is rapid, the febrile paroxysnvs severe and quickly recurrMit, 
if there he much supiiuration, and the genei-al health be indifferent or bad, 
the prt^iosis is grave, 

3'reatm^aL — In the acute state, venesection, leeches to the lymphatic to- 
aeU, fomtMitations, rest, position, eold lotions. Internally, saliuA, mercurv- 
ftlii. Ill the chronic sute, fiiction, i)reMure (continuous), bandaging, hlis- 
twring ; and, internally, iodide of potaasinm, Uiiuor potassw, bromide of 
potassium : and, ns a last resort, ligature of the main artery running to the 
limb or tumor; pressure; and rest. Mr. Waring recommends quinino. . 



er daclt _ 
current. 




^mp2 



FiBBOUA. 183 \ 

Vanitetti bus siicceasfully employed comiii-ession of the arterial trunk siip- 
plying Ihe uffecW jiai't. Dr. Biichanaa explains the action of thin proceii- 
tire thus: — Tying the main artery does not reduce the size of a uoi-mal leg, 
but does that of an elephantiasic one, because the organs of ahsorptiou act 
ditfereiitly upon aornial and abuomial tissues. The activity of ubsoqition, i 
as a general rule, is in inverse ratio of that of circulation. When the force of "| 
circulation is weakened, the process of absorption is uuuBually energetic. 
This ^plieK particularly to non-malignant deposits; and abaorptiou being i 
once 8tJii-t*Hl will often go on of itself. Thus, when a blister starts the ab- i 
ear|ition of an old elfusiou, that absorption will sometimes continue on uii- 
and this is why in elephantiasis, after the ojjerfttion, coliateral circu> 
being soon established, absorption of the morbid material goes on. 



FIRROHA (mOLLUSUUM SIMtLEX), 

Aij in keloid we saw that as compared with scleroderma, there was a ten- 
dency to greater prominence of tumor and less condensation, so in fibroma i 
another stage is reached, for the outgrowth of fibrous tissue is freer, and ' 
there is little condensation. This form of cutaneous hypertrophy has gen- 
erally been classed with sebaceous disease, but wrongly so ; it is uot due to 
dilatation of a sebaceous gland, but is simply an hypertro|>hic growth of j 
fibrous tissue, which becomes more or less pedunc\ilated — it is i 
polypus of the skin. In the early stage there ia a softiah tubercle of the i 
same ci>lor anil consistence as the luttursl skin ; it may be sessile, but soon 
gets iwdunculated, and then gradually increases in size until it may at lost | 
aasunie tho bulk of an orange. There may be one or several tumors. Pro- 
fessor Ebert reoonln the case of a man in whom there were 107. I saw a 
cas^ of Ifohiii's, at Vienna, in which the whole body was coveted by these 
tumors (of all sizes) ; one was nearly as large as a fist. The tumors are seen 
es|iectully on the neck and chest, more uncommonly ou the legs. The dis- 
ease occura in elderly jieople, and is not attended with any special danger. 
Wlten small the tumors resemble warts. 

Pathology. ^Dr. Beale, some twelve or thirteen years since, gave a de- 
scription of one of these small tumors, and nothing cr>u1il indicate more 
clearly the nature of the diseajie — viz., an hypertrophic growth of the fibro- 
celtnlar element of the skin. He found that the gland-ducts could be traced 
independently of the tumor, being, however, often pushed aside or other- 
wise interfered with. A section of the tumor exhibited sjiaces leA by the 
ieiiai-Htion of (ibrca, and these were filled with cells. Dr. Beale concludes 
that neither the sebaceous nor sweat glatids, nor their duots, were concerned 
in the formation of the tumoi-s ; — that the disease is really a morbid altera- 
tion of the structures concerned in the formation of the hair, particularly 
thedeoi) cells of the follicle. Dr. Beale also noticed that the subcutaneous 
ftreolar tissue was hyi«rtrophied, I should add that the hair-follicles and 
htur are only alt*>re(l by the pressure of the tumor. 

The miun charact«riBtics, as compared with keloid and scleroderma, are, 



1S4 nypEBTROPnic and atrophic affections. 

the free outgrowths and the absence of any condensation — the new tissue is 
lax and open. 

The Diayno^is must be made from sebaceous cysts especially : in a C}'st 
the origin from a fat gland : the central a})erture or entrance to it, and 
the fatty contents which can be squeezed out, det^mine the nature of the 
disease. 

The Treaimmt is simple : when small, remove. In elderly men the\' are 
sometimes small, flat, and numerous, especially about the back, ov<;r the 
shouldei*s, and on the chest. I have never had the least trouble in getting 
rid of them all by the use of acid nitrate of mercury caustic to the smaller, 
and tlie joint use of that remedy and the ligature to the larger ones. I 
generally, after applying the acid, give an oxide of zinc paste to be used, 
to pi-event too much irritation. 

There is yet another fonn of fibrous hypertrophy, in which gi*eater laxity 
of tissue is observed. It is called — 

DERMATOLYSIS. 

In this affection the skin hangs in loose folds. Its fibro-cellular element 
is greatly inci*eased. The affection really includes all pendulous conditions, 
from obesity, ]>arturition, the state of skin in lax and enlarged mauuuie and 
the like. 

Valentine Mott has called it pachydermatocele. In the uncomplicated 
form of disease, the hypertrophic growth an*anges itself in layers like the 
folds of a tippet ; tliere is little vascularity ; the sensibility of the part is 
diminished. Five chief seats of disease are mentioned by Alibert — the eye- 
brows, the face, the neck, the abdomen, and the labia. Mr. Funieaux 
Joixlan has described what appears to be the same disease, occurruig in a 
collai'-like mass around the ankle. I saw at the Ortho}>»dic Hospital, some 
few yeanr since, under the cai*e of Mr. Adams, an instance of this disease 
affecting the whole leg, and associated with pejidulous folds, lax and soil, 
on dilTei*ent parts of the body. 

GENERAL REMARKS ON THE GROUP. 

Now the six iliseases that I have placed together in this section of the 
work are h)>ociully characterized by hYiKJi-ti-ophy of the fibrous element of 
the skin ; in morpluoa thei*e is no elevation, but condensation is specially 
marked, and the whole derma, and pi*obably the cellular tissues, are affected. 
In scleixMlerma, the coiium and the cellular tissue beneath are affected, 
whilst the |>apillary layer ivmains apimi-ently uninvolved : thei-e is still con- 
densation, but more prominence. In keloid the corium is si)ecially affected ; 
thei-e is less condensation, and the papillary layer of the derma is more or 
less uivolviH.1, whilst in dermatolysis we have still less condensation and 
more prominence. The essential nature of the change apjiearH to be the 
same in each case : the i|uantity of lymph and its contractile quality varying 
much. 



OENERAL REMARKS ON THE GROUP. 185 

But what I wish to insist upon is this : that microscopic examination 
(especially that made by Rasmussen) has shown that the changes in pai*ts 
other than the fibro-cellular element and the lymphatic system are second- 
ary. For some time the blood-vessels, nerves, and glands are unaltered, 
and they are only changed by the accumulation and pressure of the foreign 
deposit. The disease does not commence in them ; but then comes the 
question, what is the oiigin of the change in the fibrous tissue ? Does it 
originate in it ? and what is its connection with disorder in the lymphatic 
system ? Some few years since I attempted to prove, and the papers are 
published in the ^^ Obstetrical Transactions,^' that the fibrous deposit ob- 
served in phlegmasia dolens is connected with disorder of the lymphatic 
system, as cont;*asted with the oedema that arises from venous obstruction 
simply, and I argued that the lymphatics were specially concerned in the 
nutiition of the cellular tissue ; that there was a constant fiow of lymph 
from the arterial capillaries to the cellular tissue, to meet any unusual re- 
parative demands (the cellular tissue being the material for the repair of 
wounds), that the lymphatics seem to regulate the supply, and remove all 
that is not required ; lymphatic obstruction, therefore, means hypertrophy 
of the fibro-cellulai* tissue (if suppui*ation do not occur). To that opinion 
I hold : the history of bucnemia tropica (which lymphatic inflammation is 
the first and necessary stage), and the researches of Forster and Kasmussen 
(showing in scleroderma, alterations in the lymphatics) clearly point in the 
same direction, and I am convinced that we shall some day connect these 
hypertrophies of the dermal tissue with some disorder of the lymphatic 
vessels. In fact, Rasmussen notices that an erysipelatous attack precedes 
scleroderma. It is thought that the changes in the skin in morphcea, sclero- 
derma, and the like, are the result of primary disorder of the nerves ; but I 
think in that case we should have moie evidence of disordei*ed sensation as 
an antecedent, and more atrophy ; and, moreover, we should not have hyper- 
trophy. That is my difficulty in allowing that the mischief is in the nerves 
primavily ; as it is, the anaesthesia or pervei*ted sensation is a late feature, 
and follows the deposit in the skin. Upon the supposition that the lym- 
phatics are mainly concerned in the regulation of the nutntion of cellular 
tissue, it is easy to see that keloid may very likely arise in cicatrices, the 
material of which is cellular tissue. However, I am quite convinced of 
one thing, that lymphatic obstruction means the collection of a large 
amount of fibiinous lymph in the meshes of the cellular tissue (supplied by 
the blocked-up vessels), which may be utilized to form the proper fibrous 
tissue. We see this on a small scale, as the result of the obstruction to 
the lymphatic circulation that occurs, in cancer. This same theory of the 
office of the lymphatics accounts for the similarity that exists between the 
skin changes in bucnemia, morphoea, scleroderma, and keloid. Some author- 
ities believe that elephantiasis Grsecorum is an ally. As a result of those 
special conditions that generate elephantiasis, deposit may take ))lace in the 
wlmJe skin, which hypertrophies ; the deposit is found round the nerves 



Iftfl IIYPERTEOPHIC AND ATROPHIC AFFECTIONS. 

niul the vohsoIh, and morphoea results ; atrophy and an»sthesia do not ratnlt 
till tlio vohhoIh and nerves are seriously involved. 

T\\v> primary cliango is in the areolar tissue, rather than the nerves. It 
will 1m) rccollocUHl that Dr. Carter has pointed out that the site at which the 
norvtvtrunks are s]>ecially affected is the spot where they perforate the ha- 
cia. On tho wholo, then, we must i4^ree that an examination of the pathol- 
ogic^H of oK^plmntiiisiH, scleroderma, keloid, morphoea, show a close similar- 
ity in tlio soat and character of the changes in the skin, tend to prove that 
tho lymphati(*R in oach case are si)ecially concerned, and that the material 
of infilt ration by its presence and pressure produces aniesthesia, serious dis- 
turlMinivs of tho norves (marked in elephantiasis because of the d^^ree of 
diMoaM^), and more or less obliteration of the vessels and dncts. Whether 
tho nmtorial do|H>ait«Hl is the same in kind in all cases cannot be fairly de- 
oidiMl at prt«wit^ 

An 1 havo said, I fool sure some of the diseases, which I have described 
undor tluH h(>ad, will come to bo regarded as in great^measure diseases of the 
lymphatio systom. I n^grt^t that wo are so much in the habit of ignoring 
tho inrtuomv of tho lymphatics in tho production of du 



lM$i^Rl>RRS OP THE VESSELS, OR VASCrLAR AFFECTIONS. 

This gnnip inolutlo« thi>sio diseases of the skin which are called nevi, and 
al!«(^ x artixv^^ voius. A na»vus is simply a hypertrophied state of the vess^ 
of tho skin« iHVtipying a gn^tor or less extent of surfiioe, from m lun-point 
tx^ a >M holo rogitnu or alm^^st limlx. Thoy may be ocm^emkal or ao^imi. 
W^iou iho vonous tifemio pnislominatos thoy are called tchoim, and when the 
aiiorial I'^pillariiMt aro nn^t cv^rnvmod. arfrrioil nievi: the color is brighter 
in tho Uitor itftM^. In K>th claAW» tho tiopth of siuC spe affected Tariea. 
Whon it i:fi sU)vri)oial anti slvshtly raist>d« and the vcooos ndicleB are affect- 
o«U >i^v haw iho )v>rt-«ino mark or daret stain. Nirvi aiY oftentimes asso- 
oiat^x) « uh picnioni «io)>i>MT in thonu axni may l^ covered with hair. Some 
u)hV^(>^^ >.n)o oharu^: ^>«i)«^ st)f>a«li\ inomij^ by tho hyp(rtiv|thy of old* or 
tho «to\YNM<kn)oaii of i>o^ ia:s4io; iho latTor asmmo the as}«en of what are 
oa;i<M ort\^iV t;;vt>«^r^. Miorvij^xxtio <\an:inata4^s^ow» that the ooata^ call- 
KiVs. an^i t^«i)A>s «yf iho x-o»«-ls aro all hrx^erxrv^ihMd aa»d «iikaivd. X»- 
> »«. a:^^>^^is 11^ iho Y^r.>o ci>'or. to a smal^. lurx-ns of aoadcBtal origin, in 
>»V.>oK th/^^ In a ^vr.tnral )v\'w;^^'»r<r.T T>(\i ti^ ^t jt axmrriiana} ^ihattan of an 
aitsrt^jkl KxNi'* >»*:?>; x**"^'^* TTHtiijiiinc T^iow'tTk-w;. 

H>i>^iAv^>,> '"^t u?r XTU» ^»;\v.*rt !>. fro. w-r.th fwsb. and may be caused 
^^ »nV«>.k^n-i*,%t. t," :W oy.>»'*':v; fj,-^ ,-.•* ),'i.x\.i. .-c a naMO*! wKbt <rf ttme in 
iKr x*<^sj<€^)x ^1 ,vvi:'> ^X^ri *.W '•ms^ xv.*-^ ^rsv:ii«.tS", vtM ia the ^rins of 



DKVELOPKBSTAL PTSEASSS. 1S7 

we may puss threads thi-ough vaiious ]iart« of the iiiaas,leave them foe twenty- 
four or forty-eight houi'B, till nome slight iiTitation is set uji ; then i-emove 
them, HO that the growth may be obliterated by iuflammation. Or we may 
inject perchloriile of iixtn ; bttt the eilk-tlireacl treatment in nincli the best. 
Ueuce nitiic aci<I, ejciaion, and the use of silk sutures are the chief meam 
of cure. So-calletl pigmeutaiy mevi are rightly described iiniler the head 
of Mttciilu*. 

It should not be forgott«u that purpura hag been shown to be probably 
counecteil with Bpecial morbid changes in the capillary blooJ-veBsela ; tbis 
is referred to imder the head of Purpui'a. 

Under this heail may be noticed another mixed form of tnmor, to which 
the name of nmvoid lipoma ia given. Mr, Eriohaen has described it as fol- 
lows: — ''It is a tumor in whieU the nwvoid structure is conjoined witli or 
deposited in a ccllulo-adipose mass. This disease is invariably seated ujion 
the nates, back, or thigh. It occurs as a smooth, doughy, indolent tumor, 
incompresnible ; not varying in size or shape ; without thrill or pulsation of 
auy kind, possibly having a few veins ranufyiug over its surface, but no dis- 
tinct vascular appearance, It is usually congenital, or has been noticed in 
early life." After removal it ia found to be comiwsed "of a celtulo- adipose 
bnae, having a lai'ge number of veins ramifying through it, so as to consti- 
tute a distinct vascular element communicating with small cysts containing 
■ bloody fiuid." 

DEVELOPMENTAL DISEASES — VIZ,, SERODEIIUA ASD K'llTUVOSIS. 

I thought it unuecessary to make a separate grouj) of ibe two forms of 
the same disease — nei-odemia and ichthyosis — the niain feature of which in 
each L-ase la the free formation and accuniulation of ejiitlielial scales, uit«r- 
mingled with more or less fatty matter, and forming branny scale's, or hard, 
liomy, platy masses. It has been usual to dcRcribe a true and falst) ich- 
thyosis according as the scatiness was made up of epithelial cells mainly, or 
associated with &tty nuitter in large amoimt. I quite agree with Mr. 
Hatchiuson that the distinction is less reul than b generally HU|>])osod — the 
difference is one of degree, not kind. Now ichthyosis as a primary form 
of disease is not inHanuuatory, but often hereditary, and mostly congenital. 
In it tbe perspiratory function is arrested, the whole tone of the skin ia 
lowered, and, as before observed, the epithelial cells are not proj>erly though 
freely formed, and together with the fatty matter of the glands collect into 
plalea or masses. The dry state of akin is remarkable. A caking on the 
Kurbuce may result from sebaceous flux, and this will be described under the 
head of glandukr diseases; it is different from iclithyosis, a congenital disease 
aaitodaled with a generally disordei'ed state of skin, which is not present in 
sebaoMiu flux. The least expi-essed form of the disease is called : — 

XEBoDEBSA (day skin). 
^^Ib tBu Tuiety of disease the surface is peculiarly dry, harsh, ill-nourished, 



]S8 HYPERTROPHIC AND ATROPHIC AFFECTIONS. 

and wrinkled, instead of being sofb, elastic, and smooth. It seems as if the 
skin had not been developed so as to keep pace with the growth of other 
parts. There is less subcutaneous fat than usual, and therefore the natural 
lines and furrows are mapped out very distinctly. The skin looks dirty, the 
nails are ill-formed, but, more than this, the surface is covered by thin cnti- 
cular scales or plates, free and loose at their circumference, but attached in 
their centre. Tlie aspect of the scaliness varies somewhat ; it is mostly fui^ 
furaceous on the head, in plates on the face, farinaceous about the eyelids, 
the neck, and the trunk, where it is also scaly. When the scaly condition 
is well marked, the variety is termed ichthyosis squmnosciy or simplex. Now 
the whole skin is involved in this want of development. The glands^ there- 
fore, do not secrete properly — the perspiratory, hence the dryness ; the se- 
baceous, hence the collection of altered sebaceous mutter with the epithelial 
scales into large plates or horny masses. The disease when marked consti- 
tutes : — 

ICHTHYOSIS. 

But it vnll be understood that xeroderma and ichthyosis are degrees of one 
and the same thing, only in the former there is chiefly epithelial sqaama- 
tion and less fatty matter secreted ; in the latter the sebaceous secretion 
does not pass away insensibly as usual, but gets incorporated with the epi- 
thelial cells into j)lates, wliich are hard, dry, and dark-colored, and vary 
very considerably in thickness. I have lately had two ^latients in whom 
the xerodermal form coexisted with the homy variety of ichthyosis. 

Now, ichthyosis may be divided into I. squamosa, I. spinosa, I. cornea, or 
hystrix. These terms sufficiently explain themselves. The disease may be 
in large plates, or in spines (porcupine disease), or in extensive patches, 
dark or black, having the aspect of the bark of a tree. The masses can be 
picked off, and the skin beneath looks dry and shrivelled ; in some cases the 
openings of the sebaceous follicles are seen to be somewhat dilated, and on 
the under surface of the detached plate are seen little plugs which have fit- 
ted into the ducts of the sebaceous follicles. In other cases, about the 
ankle, etc., the papillse of the skin may be considerably hypertrophied. Pa- 
tients affected by any form of ichthyosis are somewhat thin perhaps, they 
feel the cold weather terribly, and when this is severe or windy the skin 
becomes irritable, tender, and often cracks. The parts especially afi*ected 
are the knees, elbows, and those about the ankles, the waists, and the axilln. 
But the dcgi'ee of surface over w^hich the disease is marked varies ; it may 
be pretty genei*al or local, but however extensive it is, the skin generally is 
dry, harsh, mapped into small spaces, and scaly. When the disease ia local- 
ized, the legs, ankles, and forearms, and parts about the elbows, are speeiaily 
the seat of the hominess. 

Etiology, — Ichthyosis and xeroderma are often congenital, at all events 
develop very soon after birth. Ichthyosis is frequently hereditary, uid 
affects the same sex through different generations. 



ICHTHYOSIS. 189 

Patliology, — ^The scales are made up of epithelial cells, intermingled with 
a varying amount of fatty matter, with or without hypertrophy of the pa- 
pillae of the skin. It is the general want of development and arrest of nutri- 
tion of the skin which makes the disease a separate and distinct disease, as 
contrasted with pityriasis and the like. 

Treatment, — I have been pretty successful in getting patients into a con- 
tinuously comfortable condition. In the first place I am careful to see 
that patients are cleanly, that they are well fed and clothed. I then give 
cod-liver oil, and such remedies as qtdnine. I don't exhibit arsenic. Lo- 
cal remedies are the most important. In xerodeima, any plan which sys- 
tematically keeps the surface greajsed and slightl}*^ stimulated will benefit. 
It is immaterial what grease is used, elder-fiower ointment is as good as 
any. In the homy forms of disease, a clean surface may be very readily 
obtained by careful soaking with glycerine, by poulticing, or foment- 
ing. The best plan is to use an alkaline bath, or, if the disease be too 
extensive, a warm alkaline (potash | ss. to f viij.) lotion, to soften up the 
masses. After these are removed in part by picking them away, the whole 
surface can be greased, and an alkaline bath used twice a week, | iv. to 3 vj. 
of carbonate of soda and bran, to the usual quantity of water. In this 
way the disease may be controlled so as to prevent it being not only a dis- 
figurement but a discomfort, save with occasional attention in winter. 

SPURIOUS ICHTHYOSIS. 

I had better repeat that the spurious ichthyosis is that form of disease in 
which the amount of fatty matter is large as compared with the epithelial. 



CHAPTER XVIII. 

PARASITIC DISEASES. 

These are such as are necessarily connected with the development and 
growth of parasites, and they may be divided into two classes : — 

A. Dermatozaicy or those produced by, or associated with, the preeence 

of animal parasites. 

B. DermatophytiCy or those in which vegetable parasites are concerned. 

I do not now refer to disease connected with parasites found in the interior 
but only the exterior of the body. 

We are ignorant of the exact kinds of soil which are fiEtvorable to the 
growth of parasites. The attacked sui'faces are certainly not those furnished 
by healthy people. In animal parasitic diseases uncleanliness plays an active 
part. Vegetable parasitic diseases occur in ^^ lymphatic ^ subjects. 

The parasitic animal or vegetable having found a congenial soil, produces 
certain results, which are diagnostic. Independently of this, in all instance 
the parasites act as local irritants in common with a host of other things. 

Parasitic disease is really composed of three conditions : — 

a. A suitable soil. 

b. The parasite. 

c. Certain lesions produced by the parasite (whatever it may be which 

is present) which are characteristic, as the acarian furrow in 
itch, or the biittleness and dryness of the hairs in ringworm. 
In addition there may be secondary or accidental features, such as ecthy- 
matous s|K)ts in scabies, chronic lichen sometimes following an attack of 
itch, suppuration of the sebaceous glands in ring^'orm, &c. 

Tlie characteristic lesions of course will be fully detailed in the descrip- 
tion about to be given of the vaiious forms of parasitic disease. 

A. TiiE Derxatozoic, Eitozoic, or Animal Parasitic Diseases. 

Tlieso are as follows : — Scabies or itch : trichinosis (? disease of the skin) : 
phthoiriaAis, morbus |>ediculans or |KHlicuIar disease : those associated with, 
the development of"bots,'' the chigoe, the dracunculus, the leptus, the flea, 
the bug, various gnats, and lastly the stoatozoon folliculorum. The latter 
|>arasito is n»fem»d to under the head of acne. 

81UU0 of thoijte nH]uirc but little notice. The tlea {P^tfex irritan$) makes 
its bite and produces a little circular erythematous s]iot« with a dark speck 
in the ivntre, marking the wound ma^lo by the insect ; the irritation may 
extt'ud, but getierally quickly sulisides, leaving a little dark ecchymoaed 
point smaller than a *|>in*3 head behind. Tlio bug {Cimer iedtUariui 



AimcAL FABABinO DIBSASES. 



181 



or Acaudiia leclularia) produces a rather more luiirked condition of things ; 
there is a good deal of swelling, a little intiltrotion of the Bubcutaueoua cel- 
lular tissue, in consequence of which the |)art or sjiot feels tumid, hot, aud 
tender: little "bumps" of this kind me noticed oftentimes all over the 
hodj. Tlie central point is not dark but light, and exliibits the bite of the 
insect. It cannot well l>eco[ne the subject uf mistuke. The best treatment 
is the application of a little Bpirit lotion. A fomi of urticaria may be caused 
by the imjuictiou upon the surface of the little hiurs of some of the larvw. 
The BtttLckBof the leptus autunmalis, or harvest bug, are well known, as 
producing erythema and papulation. 

Sometimes the skiu, esj>ecially in the South Americans, is the seat of the 
development of the (cstrus, the " bots," or " gadfly," as it has been variously 
termed. The larvsa burrow under the skin, giving rise to " circumscribed 
(umnculoid tumors " the size of a nutmeg, which appear to give exit by a 
small aperture to a sanious discharge. Presently these open and leave ul- 
cers behind. The insect is called the mosquito-worm : it bears close restun- 
blanoe to the mstrUB buvis. In a case re|>orted by Dr. Duncan, there was " a 
little lump at the back of the neck, which slowly changed its position in 
various dii-ections ; tlien a hole opened over it, and a worm was Bi\neezed 
out.*" Two or throe similur ocouri'ences took place. It appenra that the 
patient (a girt) had herded some cows in Perthsliire. The larvH were those 
of (EstniK bovis. Dr. S{ience has seen people in Shetland attacked by the 
some thing. " The larva occur in exposetl parts of the body, and in those 
who are loosely dressed." The diseaiie is eeseatiolly characterized by the 
presence of little painful lumps, which shift about: a little red eccbymotio 
line murking the track of the insect. The parasite is the oistrus bovis, 
order Dipt«ra. 

Tlie chigoe (Pvlex or Sa^cop»ylUi penetrans), or chiggre, is a common 
cftuoe of disease in the West Indies. The chigoe attacks the feet and hanila, 
entering the skin beneath tlie nails or betwixt the toes, either hy a channel 
made for itsolf, or by the ducts of the skin: it takes an oblique direction 
nn<ler the epidermis, and its tract is said to be traced as an "elongated 
brownspot." As the insect gets deeper, this goes. " The bands and feet of the 
parasil« then become hidden beneath its own stomach, which enlarges rapid- 
ly, the upper part aloue of the insect being jierceptible through the epider- 
mis, under the form of a milk-white spot. This S[)ot enlarges considerably 
daily, until it looks like a large ii'eckle, insensibly meanwhile changing its 
milk-white color to a ]>early gray. By the time the animal is ready to de- 
posit its eggs, it has become, says Dr. Guyon, literally all gltiiinieh, and this 
period may be known by the ashy-gray color of the e^s, wliich are visible 
through their ti'aiisjiai'ent envelope. The eggs now come forth one by one 
with astonishing rapidity, foUowing each other through the layer of the epi- 
dermic, which reoi>eus for them the passage previously made by the entrance 
of the pAraaite. The departure of the eggs brings to a termination the 
_9SatAeow uf the insect. It then perishes,, attached entire, head, feet, anil 



I .- -._i. 



THE OmWEA-WOKM DISEASE. 

FAwn oat H little way. Its average length is eigliteen incliea ; it ta&v be 
longer^ — three or four feet in the African Hpecies. It is milk-white, 
^Undrical, elightly flatteaed laterally, anil tajiers towards either end. It 
about ^gth or y^tb of an inch in tkicknesB.] 

Tht Mode of Attack. — When the worm is very minute it finds it« way to 
ime part of the surfece, generoJIy the bwe feet, and " bores " ita way decijily 
dto the skin, where it takes )i[i its abode. It grows in six months or so in 
perfectly quiescent stat«, as far as the patient is concerned, till it reaches 
length of from six inches to two feet or more, half or two-thirds of a line 
1 thickness, and looks like a bit of whii>cord, pointed at either end. When 
i rSHohea a largish size, the worm begijis to find its way to the surface. A 
feU i^peara, this breaks, and the worm protrudes ; a good deal of irritation 
f£ titb general system follows, and the suiforer is disabled fur a while. The 
IS have the power of travelling from place to place over the body. It 
■ ipnerally felt under the skin as a " cord." 

The particular Part of the Body attacked. — In the vast majority of 
iwa the lower extremities are the seat of guinea-worm disease. About 
1,000 caseH have been collected together by a writ«r &om the Indian jour- 
uls, uid in more than 9S per cent, the worm was found in sonic part 
(f the lower extremities, and in the largest proportion about the foot and 
iha anklefl. KUcheumeister ijuotes 172 coses of Mr. M'Qregor, and in 134 
if these the feet, 33 the lower part, and 1 1 times the upper part of the 
lugh, and twice the hands were affected ; exceptional conditions ore reailily 
ncplained either by the migration of the worms or other clrcum stances. 
rhe water-carriers, or Bboestees, in India, who carry a " mtisbuk " or leathern 
«g suspended from the shoulders, according to Ninian Bruce, are most 
nibjeet to the guinea-worm in those ]>arts wJiich come in contact with the 
aiudkuk. lliis is presnniptive evidence of the strongest kind that the worm 
8 derived from without, and that it takes up its abode first of all in thoBt> 
larte which come iu contact with the ground, or with articles that have 
>eea in contact with the ground. Of 3U0 cases noted by Dr. Horton, in 
JU6 the disease was in the teet. 

3T(« Imnutdiate Cauge. — Much difference of opinion has been held in 
nganl to the tiiie cause of giiiuea-wonu disease. Two things are nowa- 
li^H accused of the mischief — 1. The soil and the pools; and 2. The drink- 
ing water of the localities where the disease is found. If the drinking 
mtfr had any influence, tlie worms should be found in the stomach and 
H^oining parts, and generally diatribut^d over the body; besides, the dis- 
Mae occurs in persons who drink water of the very best kind, and in those 
vbo never take it at all. Kuchenmeist^r relates the case of a friend " of 
IftDqnin who, when in C'iira(,'oa, did not drink a di'op of water, which, as a 
lo*«r of spirituous liquors, was not very hajrd upon him; but he was at- 
ttdced by the worm, whilst Jacfpiin, who drank much water, remained fre« 
bom it. A Dutch general in Angola ate and drank nothing but food and 

KbcoMght with Jiim from Europe, and yet he acijuired the worm." 



192 PABASmO DISEASES. 

stomach, to the epiderm which had enveloped it, and with which it is carried 
finally from the individual in whom it had fixed itself. The best time for 
extracting the insect is just before the emission of the eggs ; if they are left 
to be hatched beneath the skin, great irritation and painful sores are sure 
to result." Some curious facts have been further noticed. In some cases 
of elephantiasis (? which) certain little oi)enings are seen in the skin, and it 
is said that from thence chigoes make their exit. When the insect reaches 
the dermis with his proboscis, ** it establishes between it and the dermis an 
intimate circulation, which is demonstrated by the movements of the systole 
and diastole of the heart of the subject being seen in the whole parasitical 
body, and by the vascular connection which is wonderfully perceptible as the 
vessels are becoming distributed for the nourishment of the eggs." The 
vascular supply springs from one main trunk, and vessels run off from this ; 
the main supply terminates in the end of the head or sucker, and, curiously 
enough, the movements exhibited by it are synchronous with those of the 
heart of whatever animal the chigoe fastens upon. The treatment consists 
in dilating the original chamiel of entrance, and cai'efully removing the 
chigoe bodily. 

THE GUINEA-WORM DISEASE. 

This affection is due to the presence and growth subcutaneously of the 
Dracimculus, or Filaria Medinensis, and is found only in certain tropical 
parts, chiefly of Asia and Africa; it does not acclimatize itself to cold 
climates. The chief places where it is found are Senegal, Gaboon, the East 
Indies, Bombay, Persia, Arabia Petraea, the shores of the Ganges, Upper 
Egypt, Nubia (especially about Sennaar, Kordofan, Darfur), and Guinea 
and the Gold Coast. It has also found its way to Grenada and the Island 
of Cura^oa. It has been met with not only in man, but the dog and the 
horse. It is much more prevalent at some times than others, especially in 
wet and rainy seasons, and after inundations, when it gives rise to epidemic 
disease. 

[According to recent observations, it is rendered probable that some of 
the microscopic filaridte or tank-worms, as Dr. Carter styles them, gain an 
access to the skin, and there develop into the Filaria Medinensis. These 
worms are found in stagnant waters of pools and swamps, where the dis- 
ease is endemic. At the time of entry into the body, their size is about 
j^-g of an inch. The bare-footed natives are mostly attacked, and in above 
four-fifths of all instances the full evidence of the affection shows itself in 
the legs below tlie knees. These worms possess a greater or less degree of 
boring i)roperty. After the first entry into the skin, a " latent period,** as 
it is termed, of from six to fourteen months is passed before any perceptible 
result takes place. The head begins to make its way to the sur&oe, and 
local irritation is set up, and an abscess threatens ; this presently formii 
opens, and part of the worm proti-udes; the worm is solitary in the sac, 
though there may be several abscesses or foci of dise^ise. The worm can be 



THB QUIKEA-WOBM DTBEAHE. 19S 

drawn out n little way. Its average leogth in eighteen inches ; it may be 
mnch longer — three or four feet in tl^e African apeciea. It is milk-white, 
cjUndrieal, slightly flattened laterally, and tapera towards either end. It 
IB about ^gth or y^th of an inch in thickness.] 

Th* Moite of AUaek. — When the worm is very minute it finds its way to 
some part of the surface, generally the bare feet, and " bores" its way deeply 
into tlie skin, where it takes up its abode. It grows in six months or so in 
B porfcotiy quiescent state, as far as the patient is concerned, till it reaches 
K lengtii of from aix inches to two feet or more, half or two-thirds of a line 
in tfaidknesB, and looks like a bit of whipcord, pointed at either and. Wben 
it reiiohes a largish size, the worm begins tc find its way to the surface. A 
boil appears, this breaks, and the worm protrudes ; a good deal of irritation 
of the general system follows, and the sufiarer is disabled for a while. The 
worms have the power of travelling from place to place over the body. It 
is generally felt under the skin as a "cord." 

The pariictUaT Part of the Body attaeked. — In the vast m^ority of 
CAMS the lower extremities are the seat of guinea-wonn diiiease. About 
1,000 cases have been collected together by a writer from the Indian jour- 
nals, and in more than 98 per cent, tike worm was found in some part 
of the lower extremities, and in the largest proportion about the feet and 
the ankles. Kitchenmeister quotas 172 cases of Mr. M'Oregor, and in 124 
of these the feet, 33 tlie lower part, and 11 times the upper jiart of the 
thigh, and twice the hands were alTectcd ; exceptional conditions are readily 
explained either by the migration of the worms or other circumatanoea. 
The water- carriers, or Bheestees, in India, who carry a " mushuk " or leathern 
bag suspended from the shoulders, according to Ninian Bruce, are most 
gubject to the guineO'Worm in those parts which come in contact with tlie 
mnshuk, TMs is presumptive evidence of the strongest kind that the worm 
ifl ddived from without, and that it takes up its abode fir^t of all in those 
parte which come in contact with the ground, or with articles that have 
been in contact with the ground. Of 300 cases noted by Dr. Horton, in 
3t>G the discAKe wau in tlie feet. 

TJm J-mmediaU Cause.— Much difiference of opinion has been held in 
i^jard to tlie true cause of guinea-worm disease. Two things are nowa- 
days accused of the mischief — 1. The soil and the pools ; and 3. The diink- 
ing water of the localities where the disease is found. If the drinking 
water liad any influence, the worms should be found in tlie stomach and 
adjoining parts, and generally distributed over the body; besides, the dia- 
eaae occura in {persons who drink water of the very best kind, and in those 
who never take it at all. KUchenmoisl«r relates the case of a friend "of 
Jacqniu who, when in Curai^oa, did not dilnk a drop of water, which, as a 
lover of spirituous liquoi-a, was not very bard u]>on him ; but ho was at- 
tacked by the worm, whilst Jacquin, who drank much water, remained free 
&om it. A Dutch general in Angola ate and drank nothing but food and 
JwHpvges brought with Jiim from Euivpe, and yet he acquired the worm." 



194 PARASITIC DISEASES. 

There seems little reason to doubt that the worm finds its way almost 
invariably — practically always— direct from the ground to any unprotected 
part which is brought in contact with it, and, in virtue of its boring pro- 
perties, it effects an entrance. The leg is the part usually unprotected and 
exposed, and the frequency with which it is affected points to this view as 
the correct one. Then, where are the worms originally found? They 
would seem chiefly to abound in stagnant pools and swampy places, for 
there is a large amount of evidence to show that bathii^g in ponda and pools 
where tank- worms and creatures of a similar kind exist is followed by the 
development of guinea-worm disease. Dr. Carter has given valuable evi- 
dence on this point, and Dr. Balfour, in his health report of the Secun- 
derabad troops. In a very philosophical account of the Sti-uctnre of Guinea- 
Worms, by Dr. Bastion, a case is related which illustrates the way in which 
the disease is contracted. A siirgeon who had been many years in Bombay, 
and who had drank freely of the waters of the wells without ill, says : — 
'^ At last, however, I one day discovered that I had what at first appeared 
to be varicose veins, but which in a day or two I found to be guinea-wonns 
in my legs. At first I was at a loss to account for the presence of a guinea- 
worm in my body, till I remembered that one day whilst out shooting, one 
of my boots burst, and being too impatient to wait till another pair was 
brought, I took off my boots and stockings and went on shooting barefooted 
over a piece of swampy stubble ; and I believe that the worms entered my 
feet on this occasion.'^ The entrance of the worm to the backs of water- 
carriers is explained in a similar way. But though the germs of the w<Hrms 
exist in stagnant pools and ponds, there is abundant evidence to show that 
the worms may be got from damp and swampy places ; so that sleeping on 
the ground bare-skinned would su£Eioe for the purpose. It has been stated 
that Europeans are not subject to the attacks of the dracunculus. This is 
altogether a mistake. The immunity of Europeans is to be ascribed to the 
fact of their feet and legs being protected by proper coverings. It is tlie 
ex{)erience of those who have seen much of the disease, that where Euro- 
peans adopt the habits of natives and go shoeless, they are equally liable to 
be infested bv the dracunculus. 

TtMimenL — When the worm has lodged itself in the body for seroml 
months, as before stated, it makes its way to the sorfiftce, and should thm 
be seixed and traction gently made ; as much as will come forth readily is 
bound round a stick, or a piece of card, and £uiened over the wound. 
This operation of ^' winding ^ the worm is repeated daily, and at the end 
of several weeks the whole is removed, and the wound heals. If the worm 
be broken, and any portion be left, the seat of disease is attacked by severe 
inflammation. Dr. Horton states that the use of assafcetida at <mce deter- 
mines the cure ; it destroys the worm, and pre\*ents inflamTftft^^"^ and sup- 
puration. In the case of the leg, amputation may be required to be per- 
formed to save life. The secondarr Kealts are, according to Dr. Horion, 
stiff joints, contraction? of the masdeC| talipce^ swellings about the malleolos, 



PEDICUI.AB DISEASE. 195 

morti£catioii of toes, enlargement of the scrotum and testicles, enlai^ement 
of the )>reaBt, and bucnemia. 

Dr. Horton lias recently written an admirable essay on the subject, con- 
taining his experience of the disease on the Gold Coast, and I heartily 
recommend it to my readers. 

THE TRICHINA DISEASE. 

This disease, which is attracting so much attention, I have no right to 
discusa here. I name it for completeness' sake. 

PEniCULAK DISEASE, KALIS PEDICOILI (WILSON), OE FHTBEIRIABIS. 

There are three species of pediculi or lice infesting the body, — the P. 
eapilig, the J", corporis vd vestanenti, and the P. pubis, or head, body, and 
pubic louae. It is a disputed point whether they be the real cause of dis- 
ease or only a complicating source of irritation. The pathognomonic evi- 
dence of the presence and attack upon the skin of pediculi is the louse 
bite — the flat and reddened papule with the central dark puncture or 
wound made by the insect. Whatever else occurs (excited, it may be, by 
the irritation set up, and the consequent scratching) depends in greatest 
measure upon the special nutritive condition and tendencies of the attacked 
in each particular case. In one instance it will be pj~ g 

prurigo, in another ecthyma, and in a third, urticaria; 
or an impetigo in the case of the scalp. Pediculi, be- 
yond the production of louse bites, acts in a precisely 
similar roanner to irritants in general ; and the im- 
petigo following or evoked by the pi'esence of pedi- 
culi, depends upon the impetiginous tendency. Just 
as much aa the urticaria so produced is due really to 
a hypersensitive condition of the sympathetic nerves 
of the skin. Some additional remarks will be found 
under the head of prurigo. 

Sometimes lice are produced in great numbers, and, 
it is said, subcutaneously. This is certainly incorrect. \ i 

The I", corporis ia whitish, and gives rise to erup- lOOUi pmm o( an inch, 
tions, already described. See Tig. 3 (after Anderson). *^'"™"" "P"^ "™"'"'- 

The Pedieulus capitis is seen mostly in children, and in association with 
impetigo. See Fig. 4 (aft»r Anderson). 

The P. pubis grasps the hair, a little way from the surface, and gives rise 
to pruritus, erythema, and eczema. See Fig. 5. 

The 7Veafm«n< consists in the use to the head of ammonio^hloride of 
mercury ointment ; the same, indeed, to the body and pubes ; or bichloride 
of mercury lotion, with baths, plenty of soap and water, and, if necessary, 
sulphur or cinnebar fumigation. I have not thought it necessary to enter 
more fully into details. 




FABASmo DISEASES. 



SCABIES, OB irOH. 

TIlis a most importaitt disease to be well acqnuiited with. Its freoT 
is extreme, its features definite, audits facility of cure is certain. Biii 
takea are verj frequently made in ite diagnosiB. Scabies is aoontagioita di 
depending essentially on the burrowing of the acarus scabioi : and tiie i 
in the burrower. In from ten to thirty minutes after being placed ( 
surface, she gets beneath the skin, and busies herself with the c 
ment of a canal, or cuniculus, as it is called, in which slio lays h 
from about twenty-four (Hebra) to fifty (Gudden). She, of oootoe^ ffafa- 
ally enlai^sber canal (which ia arched) until it reachea a quarto- to tim 
Fig. 4. Fig. 6. 



Itsfreoj 

1. Bui 

poiia di 111 

idtlwf^^H 

3 comineifl^^^H 
ys her egp^lV 




Pidlnitni csiita (toiulf L 

or five lines in length ; it has been observed to be two or three iniJiea kn^ 
It is curled or tortuous, and exhibits along its upper border little daric 
specks, which are regarded by some as "breathing holes " (Oudden) ; but 
by others (Hardy and Baiin) as the excrete of the insect ; and by Hebra h 
dirt, the merv apiiearanc^ is rerr characteristic. Tig. 6 i«pr«Mnta, after 
e of the furrows with contained ova. The female may 
live three or four ntonths (?), but the partutenee of 
' the disease scabies depends chiefly upon the con- 
tinuous hatriung of the depcsit»d on. These come 
I the surfiice as the e[udmnia is exfidiated, 
■^jttst about the time the young are ready to be 
halcbeii The young female neeta the male, be- 
comes impiv^naletl, and then buiiuva. Tlie 
male acari do not bunow, b«t ge< vaitr acalcB and 
crasL 

Haviny hart\>«wl th* frmale rasconcM h«*s«Jf at tbe end o( tke fivtow, 
«fo«^|>ing out as it wvr* a litlfc cir*«W bed, and we may often timf neog- 
ttirf ibe acarus (an>) its haltittM>la«<e> as a minMe wUie ifieck at the end 
of th*> furrv^w. the K^i^trs ol' its fniit w ImmI part Iwldi^ Hfce a little da^ 
cnrvml line ; if w t<{vn ihts luinnte *|<«e)^ and insert ow needle, the 
a^iuMs will oKny ami cv^uw away, adherii^ K* it, «« renovaL This acariaa 
f irww ii.nr JveiTtbed is tht' c«i^n dia:j:Mi'<sbc mark vtf (cabM. 

Tb.* ^*\t of the buTT^^vira; ^if the acaras, which b th* e na e aAi a l CMae of 
scaKws, i* to w( tt|> KKwe or km looal irTttal*.* acMwdtn; to Ae ssaM'of the 
paiic&t's uttttiitMa. i>a a healthy a»d vbaa ifcia »» ^nai aMOoat <d mis- 




BTAOTSe, 08 1 



197 



Hbief follows; the acari, however, delight in dirt, and mn riot ah it wore on 
Hnvholcsonie surfaces. In the fii-st degi'ee, there may be simply those con- 
■ Adons which oolv necessarily accompany and constitute ^e more burrowing 
I of liie BOarus. The patient complains of itching, having all the characters 
I of tint of scabies, hut a diagnosis of/trunfuA is erroneously made; the little 
1 (bnowa are so deliwite, and unaccompanied by rednees, that they are over- 
^pgked. These csHea are rare. The only way in which the papules can bo 
BUd^ seen is by s sidf glance with the eye on the level of the skin ; they 
^^■fine, deUcate, slightly elevated, and transparent, and contain acnri — the 
^^BfoiotiB symptom is the itching at night. 

^™*7nder ordinary circiim,itaiicea the acarus sets up effusive inflammation, 
which may roach the stage of ^lapiilation, of vesiculation, or pustulation, the 
furrow niuniog away as it were &om the vesicles, which ore peculiar in so 
fiir that they are isolated and acuminated. 

The acari jirefer the bauds of adults and the thin skin between the fingers ; 
tliat is where the disease is first seen, as solitary vesicles, many of which 
have the acarian furrow running away from them ; then it travels to the 
front of the forearm, tho belly, thighs, and especially the npjier line of the 
penis. Intermingled with the vesicles a.ro papules and oft*n ecthymatous 
sjiotB, produced as a consequence of the scratching; linear abrasions and 
cicatrices are likewise formed. 

In marked cases there is oftentimes a little line of scabious vesicles around 
the lower end of the ulna, at the wrist. In the female, vesicles ara often 
seated around the nipple. Tho eruption is noticed also about the seats of 
pressure — ex., where a truss or a gart«r presses, above the middle of the 
thigh, and on the front aspect of the body. 

Variations in regard to the seat of scabies are readily oxjilained. Acari 
are frequently specially conveyed — for instance, by the child's band, to the 
mamma, by tlie hand to the penis, the nurse's arms to the buttocks of tlie 
child. Scabies seldom occurs on the face, in conseijuence of the uifluence 
of the external cold, but in cltildren there are exceptions. In children 
eruption, and eBpeciuily the characteristic eruption (the vesicle and attached 
euniculus), is often absent from the hands. Beginning about the buttocks, 
the disease is seen over tlie feet especially, the ankles and thighs, often the 
stomach and the well-covered and therefore warm back ; when on the face, 
it is occaaioually accompanied by sympathetic eczema about the scalp ; iu 
children ecthymatous pustules are present as the rule. It is said by some 
that the acari are only found about the hands in adults, and that the erup- 
tion about the body is entirely synijiathetic, Hebm thinks much of the 
eruption is caused by scratching. No doubt much of the enijition is sym- 
pathetic ; and although acari are t<i be found in largest pi-oportiou about the 
hands, yet they are oft«n entirely absent there in the child, and can be de- 
tected over other parts of the body. 

In chronic scabies we notice clinically two important facts : — 
^^i. That tJie seat of the eruption may ehift itaelf — at one time the hands 



I 



perLajjs luay be comparatively well, and tbeii ft freali devflopnient of 4 
cles and pajmlea occurs. 

2. Tbe ei-uptiuu'inay vary in intensity: it muy diDunisli in severitj, mntl 
again become eno^ei-ated according to tlie bygiemc couditions surrounding 
the patient or the state of bia bealtL. la tbe obronic cases we shall find the 
i-omains of tbe furrows occaisionally as rugged linea formed by the shrivellnl 
and broken walla of tbe furrows. This is very diagnostic of scabies (chronip). 
At other times ecthyinatous cnists aje fonued in abundance. Now if we cut 
off the upper part of the cuniculus, or take the nigged walls of old canals, and 
place them under the microscope, we fr^uently see ova, the c&sts of, or eren 
young six-Ii^ed acari, occasionally an acarus ; and these diagnostic certainties 
are also found in abundance in the orusts that form in scabies. These crusts 
may be softened up by turpentine or caustic soda or potash. (See Fig. 8.) 
Fi-equently several membera of a family are attacked at the same time. 
The itching is bad at night, and et^oked and intensified by everything that 
beats the body. Such is the description of scabies itself. 

It is necessary to make q>ecial reference to the acarus that ^ves rise to 
scabies. The female acarus is the most important of the two. (See Fig. 8, 
centi'al acai-us.) It is about a. sixtieth or an eightieth of an inch 
long. On the upper surface it is convex, and covered with short spines 
dii-eotod backwards, and by which, when in its furrow, tlie insect is pre- 
vented from retreating aloug the channel of its entrance. On t)ie oppo- 
site or lower surface, in the fiiU-grown insect, there are eight legs, the four 
front ones being provided witli suckers, the four hindermoat with hairs. 
The head, which is capable of elongation or retraction beneath the dorsal 
plate, is somewhat pointed at its fi-ee end, flat beneath, and widens out nt the 
base where it is implanted into the part between the anterior le-gs. There 
are two rows of stiff hairs surmounting the head ; the mouth is a long slit 
on tlie under surface of the head ; it is bound- 
ed on «ither side by two pairs of palpi and 
mandibles. At the base of the silt is the bno- 
cal orifice and the respiratory orifice, as stAted 
by Bourgniguon. The male (Pig. 7) is smaller 
than the female. The inner jMiir of the pos- 
terior legs are provided with Buckcrs, and the 
genital organs are well marked. The ova 
hatch out on the eleventh day, six-legged acari 
are seen on the eighteenth ; the young acAii 
tlien cast their skin, and aro provided with 
eight legs. Here is Bonrguignon's description : 
General CfiaracUiTt. — Tortoise-shaped heftd ; 
two i»lpi, adherent, lateml, hooked; false 
ifai«AMninso»h.i.i(«timAoJe™jn), palpi ; four mandibles, super-imposod in pairs; 
bidaotyl, the two superior armed with booklets; i«g», four anterior, joined 
with ambulacrum, terminated by a sucker ; ntpinttUm by buccal apeitm^ 
not by Rtigniala or ti'acheuj. 




'Mang I 



■ SCABIES, OB ncE. 199 

Ipmno/s. — Four posterior legs, jointed, eack terminating in a long liair; 
^toerea of posterior legs separated ; numerous homy appendages in dor- 
um ; subject to metamoiphoaiB ; size, one-third of a millimetre, 
Mide. — Sesual organs distinct ; ambulacrum with sucker, terminating 
e oentnd part of posterior legs; epimeres of posterior legs united ; homy 
sndages on dorsum in small nunil>er ; size, one-fifth of a millimetre. 
— Hesapod, without distinct sexual organs, 
WHiagnogU. — The following are the diagnostic points in scabies, but the 
only really conclusive proof of its existence in ordinary cases is the dis- 
covery of the finTQw and its acarus: — 

1. Absenoe of febrile disturbance. 

2. Absence of rash from the face and head (this is the rule) ; its absence 
&OU the posterior surface of the arm or body. 

3. The seat of the eruption : where the cuticle is thin — as, for instance, 
the interdigital spaces, the anterior surface of forearm, front of the body 
below the nipple-level, about the mamma of women, along the front of the 
penis in men ; in the seats of pressure — as, for instance, about the groin 
when trusses are worn, over the ischia, and about the inner line of the 
wrist, forming a semicircle ; in children — the buttocks, the feet, eejHicially 
the inner line of the sole of the foot, and the palmar surface of tbe hands, 

I The isolation of the vesicles, and their pointed shape. 
The mvltifvrmity of the eruption — namely, the intermingling of pap- 
vesicles, pustules, scabs, and even tjmall ulcers. 
The itching at night, and the peculiar linear scrHtches made with the 
and fringed with dried blood. 
The cuniculua or furrow — in pustular scabies few, 
u. The evidence of contagion, or the eiustence of the same sort of disease 
in one house or family. It is in chUdr<::in that the greatest mistakes are 
made, simply from the want of knowing that scabies does not prefer their 
^^^nds and arms, but their feet and their buttocks. 

^^Btf. The presence of acari amongst crusts, detectable by the microscope. 
^^^Bcabies may be confounded with : — 

^^KrXiiclien, — But in lichen the ei-uption is unifotTn, There are no vesiclea 
or pustules. Lichen occurs on the outer aspect of the forearm. The skin 
generaily is dry, thickened, and discolored. And though the back of the 
hands is sometimes attacked, the interdigital spaces do not sufTer, The 
itching is different. There are no cuuiculi; no acari of course. It does. 
not occMV about the seats of pressure especially. TItere are no rhagades. 
pro duced by scratching ; and the rash is oeen frequently about the face, and 
^^Bfeci over the back, 

^^^BVurt^o, — In very many cases of scabLea the papules become jiruriginou!^. 

^^^^ not to such a marked degree as in prurigo ; and this is only in scabies a 

feature superadded. The prurigo of scabies is seated about the beUy «id 

the anterior surface of the forearm ; whilst in true prurigo the papules are 

Mattered over the outer aspect of the limbs, over the back, above the level 



I 



200 ^^^^^^SaSi^o dissassb. ^^^^^^^^^^^^^ 

of tlie nipple-line, around the neck, in greatest profusion; aud alxmt tlia 
legs. Moreover, there are no vexioles, though in old-Btaading caaea eclitlij* 
matouB pustules may be developed. But here the origin from prurigo, and 
not scabieE, is traceable. Then the nkiu in prurigo is uubeaJlhy, the aieaa 
of Bkin enclosed by the natural furrows are exaggerate, and a condition at 
''uiiication" results — oftentimes well seen on the back. Pediculi ai-e often 
present ; and tlio sensation is not itching so much oa formication and burning, 

Stropladvs (or lAdum) Prurigi luietia, — This ia aimply lichen occurring 
in ill-fed and etnunous children, and in couaequenoe the papules are covend 
at their apices with little points of coagulated blood. This dit«eaa« lacki 
altogether the features of scabies as regards the acarus and its farrow, and 
the multiform aspect of the secoudaiy eruption; and it is made worse hj 
the ttae of mdpkwr ointment. 

Eetema. — This differs entirely from scabies, in that it is esseutially an 
oozing disease, in which the vesicles are agglomerated (and not isolated and 
acuminated), forming a patch of greater or less extent; the absence of fur- 
rows, kc., of the peculiar itching, of a multiformity in the eruption. 

SiJphw Math. — One of the commonest errors is to mistake the artificial 
rash set up by the usa of that villanous compound— the compound sulphur 
ointment of the old I'harmacopccia — -for a continuance and increase of th« dis- 
ease ; tliis has been referred to in a former place. See Medicinal Kashm, p. A3. 

Impetigo Contagiosa. — This mostly begins about the face an<l head, and ia 
transported hither and thither by the fingers in acratcliing. It looks lik* 
ecthymatouB scabies, but it is not commonly iuterdigital ; the eruption is 
unifoiiti, commencing aa iaoliited vesicles that quickly enlarge into bulla, 
with a de]>i-eBsed centre sun-ounded by a raised collar of blebbed epidenuia, 
the whole being replaced by a liglit-yellow flat scab, that looks as if " stuck 
on " to the part. There ore no papules, no furrows, no scratches ; it la not 
InterdigitiU, but attacks the outer aspect of the limbs equally with the inner, 
the buttocks, however, in children, and frequently the knees and tlie f«et ; 
the ends of the fingers rather than the palm and interdigits : and tliis condi- 
tion is always accompanied by eniptiou on the head and face. Except just 
at the outset there is no special itching at night, or day either. It is con- 
tagious and often epidemic. 

Complieated Scahie». — Almost ajiy other eruption may comuiingU with 
that of itch. This is very iniportaot to bear forcibly in mind ; the more ir» 
recognize the fact the more likely we are to prevent ourselves being [lujt- 
vled. We must manage to recognixc the co-assemblage of symptoms. 8eo- 
onilary nyphilodermata and scabies ore frequently co-ejiistent. Kcxema ii 
very often associated as a sequence, and ought not to olfer any difficulty. 
Scabies in children with congenital syphilis is not unusual. Lichen is Rome>- 
times set up and kept agoing by a fow acari. Mnny m*e» of litjim urttooMu 
are dependeut upon scabies. Again, purpura and imjtetigo contagiosa may be 
associated with scabiea. In all thette cases we generally have (I) a hiatorjr 
of acabies at the outset ; (2) multiformity of eruption, and of 
mingling of the characters of the two coosiHt«nt diseases ; (3) the ap] 



i 



HOKWSaUH BQABIBB. 



201 



snce of contagion given to what we hold to be non-contagions disease. For 
example, a child may seem to catK:h lichen froin another whom perhaps we 
know has scabies ; the truth being that a few ocaii have been transplanted, 
and produced Uchen to such on extent as to have maekod the primary mis- 
chief^ which is only slightly espressed- It is a moat excellent rule — one 
that I adopt myself — to search for scabies in all cases in which eruptivft 
disease is extensive, and accompanied by much itching at night. 

Trealtnent. — Scabies never gets well spontaneously. We must treat, Ist, 
the Bcaibies itself, killing the acari and their ova ; 2d, the necondary effocta; 
and 3d, the complications. In all cases, to all papules and veaidea, the fol- 
lowing should be applied: sulphur, half a drachm; ammonio-chloride of 
mercury, four grains ; creasote, four drops ; oil of chamomile, ten drops ; 
aad mi ounce of lard. This is rubbed in night and morning ; tlie same 
shirt kept on till the third day, when it is changed, and a wui-m bath given ; 
the ointment to be freely rubbed into the wrists and interdigita especially. 
In complicated scabies, we should treat the scabies always, acmpuloualy 
seeking out every suMpicious papule ; engrafting upon this the plan best 
suiteil to tlie complicating eruption, wlmtever it may be. We shoiilil al- 
ways remember that in complicated scabies a small amount of ucari may 
exist with a good deal of eruption. When the scabies itself in severe 
eases is well, a certain period must necessarily elapse before the secondary 
eruptions can be cured. The process of repair takes time. So we must 
not persist in the sulphur treatment till all eruption has subsided in cases 
of severity. We judge of the cure of scabies by the decrease and cessation 
of itching and of the vesicles and ]>apules. 

If we push our sulphur treatment too far, we may produce an irritable 
erytliematous state of skin which ta ofto'n mistaken for the continuance 
of the diseafie. The cure is often retarded by the neglect of cleanliness, espe- 
oially in regard to clothing. On the third day, when fresh linen is put 
on, it is bust simply to destroy that taken off, or at any rate to scald it 
tltoronghly. In some oases the skin is too irritable to bear the sulphur ; In 
tiuit case iodide of potassium ointment, which I prefer in chronic scabies, is 
l)est. We may also, with faatiilions folk, use a. bichloride of mercury lotion 
<two or threo grains to sia ounces of fluid). Sulphur baths in the treatment 
of scabies I never use ; they always seem to me U> do harm, and I have had 
oases imder my care in which the irritation so produced was excessive, and 
"troublesome to allevinte. If it be necessary to remove crusts, alkaline baths 
auay be used. Chamomile ointment, benzine, stavesacre, lime and sulphur, 
^^■nd ether applications, are also recommended. See Formula) from No. 154. 

^^^Qgil certain badly nourished and dirty subjects, the ecthymatous phase may 
Ib very well marked in scabies, in the form of lai^ dirty greenish-gray 
crusts coveiing over a red and m.oist surface : it may be well called scabies 
1 seen in the sit^s of ordinary scabies : in scanning the crusts 
the micivjscope, a large number of acari, in all stages of development 



1 



202 



FAItAStnO DIBBABK. 



are sieen. Acari, too, exist in great numbers in tLe skin. Dr. McCall An- 
deraou has been good enough to let me copy liia reprefientstion. See Fig, 8. 
This disease is often seen in Norway, and hence U called 8. Norre^OL. The 
treatment is that of oidinaiy scabies. 




[I have met with a small s]>ecies of tick in man. Various species a 
gnats are apt to inflict woimds, eBpecially in the summer-time, which resem- 
blea musquito bit«a, Mus<|iiitoes have not been known to exist in Eng- 
land, The so-called musijuitoes, whose existoiice in England and other 
places has recently been asserted^ are all British gnats. Tlie females of the 
common gnat {Cvlex plpieng), every summer, after hattihing out from water 
t«uks and open ditclies around houses, attack the exposed parts of the body, 
and there are many other species of the same genus Culex. The mtisquito 
of the Eiviera is also a Culex. But tliere are midges, some of which an 
called sand-Hies, which tnllict wounds on the body. Such is the opinion of 
Professor Westwood. The treatment of erythematous " bumps," caused 1^ 
the bit«s of gnats, may be relieved by a weak solution of bichloiide of a 
cury or carbonate of ammonia.] 



J 



THB eO-CALLED " A"R«Y ITOH," 



THB BO-GALLED "ABMV ITCH." 

It has been asserted by array raedicnl officers of late years, that there ex- 
ists a special foiTa of disease amongst soldiers, which has not hoea described 
hitherto. It is eikgendered mostly by a camp life, but la also seen in recruits, 
and amongst the poor in the Wcinity of camps. To this disease the term 
" army itch " has been applied. It is said to have no relation to scabiee. 
The American military aurgeona are reported to have seen a good deal of it 
during the i-ocent civil war iu their country, as tlie following quotation &oin 
Dr. Hartshorne'fl handy little work, entitled " Essentials of Medicine," 
ahowB : — "During and since the late war in this country, the iikevitable 
filth of camp-life begot, among other evils, a very troublesome coutagioUB 
sidu-disease, called by the above name. Iiching, without any eitiption e:c- 
cept small papulte, characterizes it. Outaide of the army it has extended 
to & considerable number of persons. No better remedy for this affection, 
I believe, has been found than a lotion ajid ointment, composed of iodide 
of potassium and glycerine ; with water or rose-water for the lotion, and 
lard or cold cream for the ointment. Mercurial ointment, and sulphuric 
acid ointment, are also efficacious for it." 

Dr. Hartfihome, it would appear, does not think that the disease ia scabies. 
Being desirous of obtaining as manj' particulars as possible, I wrote to sev- 
eral of the leading men of the army to ask for special information touching 
the existence and nature of this so-called " army itch." Professor Maclean 
has been kind enough to reply as follows : " I know nothing of the so-called 
'army itch.' The disease (scabies) as seen in soldiers, presents no peculiari- 
ties of which I am aware. I have showu your note to several ex]>erienced 
uid very careful medical officers at Netley ; they all agree with me." In- 
Bpec tor-General Dr. Lawson, C.B., remoiks : 

'' In reply to your question regarding itch in the army, BO far as I have 
seen, the disease which is usually so denonunated is really scabies in the first 
instAnce, but under the influence of irritating applications, whether ung. 
Bulpfa- comp., snlphuret of lime, or carbolic aeid, etc., too long continued, 
a new eruption is brought out, occasionally like prurigo, more frequently 
eczematoua in its eliaracter, which may be mistaken for scabies, and if under 
thia inipresaion the treatment be continued, the secondary aflection may bo- 
«:ome troublesome, and continue for a long jieriod. Occasionally there is an 
Siiade«(uate diagnosis, and a case really of prurigo is treated as if one of 
scabies ; but this, in my experience, lias not been very frequent. 

" Thirty years ago, when I first entered the army, the usual treatment for 
scabies was inunction of the whole body with compound sulphur ointment, 
snd the usual period of treatment was three to four days. I soon found that 
■*he ointment caused much irritation of the akin in many i)er8ona, and brought 
crot an eruption of eczema, and in consequence, with my own regiment, 
dminisbed the period of ti-eatment in nearly every case to two days only, 
which overcame the original disease, and did not develop the other to any 
^^nablesome extent. 



904 FAB&WrtCI MBSABBS. 



" We tried carbolic acid for sbyci-bI laontlis last summer, for iLe treaV 
ment of seabiee, at AiUeraliot, but Ibe opinion of the mediml officwn wu ij 
no means favorable to it. It seemed to be less certain in destroying Ihft Ja- 
sect, and more ai)t to excite eczema tliaa either the aulphido of lime or tlu 
sulphur ointment, and was at last abandonetl. 

" I trust this Btatement will meet your deaires," 

The farts mentioued by Pr, Lawson are most important, and entiidj 
coincide with Himilar experience of my own in regard to the trttatinent nf 
Bcabiee. 

It will be seen, then, that scabies offers no peetJ.inrilic» when it occniv In 
soldiers. It is, however, often followed by variouH socondarr emptieii& 
But these latter are not those which constitute the so-called " army hek,^ 
of American authors eB|>ecially. That la a primary form of diaeasa, havog 
no relation to scabies, so it is affirmed. Dr. Kartshiime observes that it b 
eonlayiaus. I am not aware that tbia is thought to be the case by Ei^M 
anny medical officers. But allowing tliat the " army itch " is not Mwbia, 
how does it arise ? 

In many cases it seems to follow the undue physiological excitement o( 
the perspiratory function, caused by residence in hot cUmates, especiidly in 
those who are possessed of the rbeumatic diathesis. There is coosidervbb 
disorder of the sensibility of the skin, succeeded by a licheuoua, prurigi- 
nous, or eciematons eruption. 

Tlirougb the courtesy of Dr. Gordon, C.E., I am enabled to give the M- 
lowing interesting particulars relating to the disease, which be liaa been 
BO kind as to obtain for me. The accoimt of " &rmy itch " given by Dr. 
Perry is especially interesting and valuable. 

Dr. Sinclair writes touching the disease : " Nothing of ibis kind ma 
noticed in the men of the 33d Regiment in Abyssinia, though they vtrm 
one suit of clothes by day and by night for nearly two months, only taktog 
them otf to wash occasionally. A good deal of redness and scalding wm 
produced by the friction of the trousers at the fork — nothing more," 

Dr. Lamprey writes : — " No case of ' army itch ' occurred in the 67ti 
Regiment while serving in China, although the reputed cause of (hat di<o— 
was in excess there, no Asiatics lieing more troubled with iieiUculi tlian t^ 
Chinese, who have a saying that not one man in ten, no matter how high hu 
rank may be, is exempt from body lice. Of course our men, who wet* 
much in contact with the Chinese of the poorer sort, were not exempt &<iai 
Ijoe, especially during the winter months, but I did not notice any prurigi- 
nous results. I &ncy the good sanitation observed with regard to housiiig, 
clothing, general cIcanlineaB, exercise, and more especially abundance of good 
wholesome food, and of fresh meat in their dietary, kept the skin in good 
order, and proved good preservatives against the disease. Fur the BUna 
reason, cascM of coiiimon scabies were not frequeoit, though the Chineau an 
particularly addicted to Uiat diaease also, their food consisting chiefly of 
TC^t«bIe ingrttdients, and meat being rarely and sparingly used. 



d. UiJ 



nK BO-CALLED "ABUT ITOH," 



205 



wily believed that Chinese itch is particularly virulent and diflicult of 
rare. I have oertajiilj seen some very angry-lookiug pustules aiising from 
it, but I have tiot foimd any case resist the ordiuary sulphur ti-eatment." 

Dr. Perry's experience is contained in tlie following letter to Dr. Gordon, 
dated Royal Artilleiy Hospital, PorUmouth, 29th September, 1808 ; — "la 
relation to our conversation respecting what is called 'army itch,' and the 
infbruiation Dr. Tilbury Fos seeks regarding it, I now send you an extract 
from my re|K)i'ts for the year 1862-3 : — ' Speaking of tha sanitary condition 
of the lith Brigade Royal Artillery, as relates to the bedding su]>plied to it, 
I am still of opinion that the substitution of hair, fibre, wool, cotton, or 
even sejt-weed (zostei-a marina), for the straw now used for stuffing the beds, 
would lie heneScial, and, in the ond, justify the expense. Considering the 
very (requent chimge entailed by straw beds, and the uncertainty of the 
straw used being perfectly free from parasitic or insect life, it becomes an 
open queation whether or not one of the iliseaHes affecting soldiere may not 
be referable to its use. For some time jiust a complaint closely simulating 
itcii in many of its characters, but wLich is not amenable to the ordinary 
treatment for that disease, has been very prevalent among the troops in this 
district, and has by some medical officers been confounded with scabies. It 
appears, however, to be aoomposite affection, having several different symp- 
toms, and being a mixture of ordinary lichen and prurigo with herpes and 
ecsema, oecufiionally taking on the graver form of impetigo. At present no 
cause can be discovered for the affection, and though diligently sought for, 
no acarus has been discovered. The impression among the men is that 
" the blankets have something to do with it," and it appears to be just such 
a OontplfLint as might have become induced by some irritating agent derived 
from the straw composing the bods. The suspicion that it was so induoed 
arOflo in my mind from my having seen umny cases of a similar description 
in the workliuuses of Hampshire, the disease occurring amongst tramps and 
Qawies who, as the nightly ocou{iantB of the casual wards, had nothing but 
Itraw to lie ujion, and in whom, to my own knowledge, the sulphur plan of 
treatment proved useless. It might have "been but a mere coincidence, and 
&ttnoHpheric influenoos alone the cause of the complaint, but to a certain ex- 
tent these views have been home out by observation lately made in America, 
«here in the Federal army a bastard kind of measles was apparently in- 
duced by a fungoid condition of the straw used by the soldiers as bedding. 
Careful ejiaminatiou of the straw used by the Royal Artillery in Porta- 
Inouth was made, but the microscope failed to discover any parasitic growth 
nCUched to it. Still the interesting fact remains that in all probability a 
diseased condition of straw is capable of exercising evil effects upon those 
Uaing it as bedding, if the American observations are con'ect,' Some time 
after the above remarks were written I had a conversation with Mr. Eras- 
tuns Wilson upon the subject, and his opinion was tliat the complaint had 
been introducd into England by the army from the Crimea, that it had at 
^^^Attacked the poorer population, but was gradually affecting persona of 



306 PARASmO DISKABES. | 

higher social status. He vraa under the impression that the peranlphide of i 
' calcium (which has been used for so luaay years past in the army for the 
GUI'S of scftljiea) would also cure the complaint in (question ; but my experi- 
eace is against siicb, as although I have found sulphur oocaaiomilly do good 
(probably where, also, there is a complication of acabies itself), yet that it 
would not'entirely eiudicate the disease bo closely simulating tt. The best 
remedy for the complaint I found to be the foUonng as an extemnl a|^li- 

" ^ Zinci oicidis 3 j,, hydmrg. ammoii. chl. 2 j., acidi hydracyaatci dilnti 
3 as., glycevinie ^j. : ft. lotio; and the following mixture intemallj: — 3 
£xt. taraxaci % tij., liquor bydrarg. bichloiidi ^ xvj., vini colchicd | y., duct 
cardam. co. % iv., a<^ua ad OiJ. ; ft. mist., a dessert-spoonful twice daily in > 
wineglassful of water. The above mixture was made in the quantity named 
because so many men suffered from the complaint. 

'* Occasionally I have found tLe disease prevail among the recnuta dnws 
from the neighboring counties, and upon one occasion I well reoollMt s 
young man telling mc that it had become known amongst his friemls by llw 
name of ' Xlorsetshu-e itch,' and that a doctor had also told him it vu M. 
At the present time the coniiilaiut is hardly known amongst iis; but at At 
time I have alluded to, it was so prevalent, and its character so little knoWl, 
that many medical officers were considerably troubled with its I 
and to my own knowledge one medical officer recommended that the b 
of a whole battery of artiUeiy should be burnt, in conseijueuce of iti 
ence amongst the men." 

I>r. MarstoD, of the Koyal Artillery, amongt others, obtained varioua 
specimens of suspected straw from different sources at Portsmouth, and cub- || 
mitted them to careful microscopical examination, but did not discover th^ i, 
presence of any fungus or other cause in the straw for disease, which was theK^ 
in existence, I suppose the same to which reference is made by Dr. P wiy J 
Dr. Marston informs me that he is of opinion that the disease has been em^* 
neously connected with the condition of straw used. Dr. Mareton adds 
— " The name is an absurd one : scabies in the soldier is the same that i'^ -3 
is in tlie civilian, and many of the coses I saw at Portsmouth were r«all^4 
those of itch ; but the affection of which I write is, however, different wA^ 
almost equally common." It is chronic ; neither insect nor ova can be do — ^ 
tected, and sulphur does not cure it. It is oflcn accompanied by symptoiD^M' 
of dyspepsia, or pi'eceded by the tropical form of prickly heat ; by hypMW*— ^ 
thesis or disordered innervation of the slcin, and is aggravated by the ub0^ 
of flannel, by sea-bathing, and by beer. I, 

The most successful treatment appears in Dr. Marston's esperience to oou- -^ 
sist in the exhibition of bichloride of mercury, taraxacum, and liquor pa- 'J 
tassiD. The disease is a mixture of pnirigo and lichen. 

Putting these facts and opinions together, I should be disposed to think ^ 
with him that the disease will be found to be a prurigo, in the true aense ot 1 
the word, mixed with eczema and lichen. | 



TSQKTABLB PASASITia DIBBABSB. 



207 



"With regard to the influence of mouldy straw m producing disease in 
camiis, I think a little conftiaiou has been made. Some American phjtiicianB 
(especially Dr. Salisbury) aaaert that a form of " measleB " may be produced 
by Botdiers steeping on damp or mouldy wheat-straw. I do not gather from 
my reading that they atti-ibiil« the pruriginous affection styled " army itch " 
to that cause, but only " camp measlea " — a different thing. Dr. Salisbury's 
account of the matter wilt be found in the American Journal of the Medical 
Sciermes for July and Octolwr, lS*j'2. It is entitled on "The Influence of 
the Fungi of Wheat-Straw on the Human System, and Origin of Camp 
Measles," and, perhaps, of measles generaJly. Dr. Salisbury records many 
facts to show that the inoculation of the system with the elements of the 
fungus of wheat-straw gives rise to the development of a diaoase which doea 
not differ from measles. He says tliat sleeping on damp and " mouldy " 
straw is the cause of camp-meaatea. He also jiroduced it artificially by in- 
oculation, and suggests that the origin of menstcs in to be sought for in 
some such manner. Dr. H. Kennedy (i^M 6? m Quarterly Journal of Jffedi- 
cal ficitna!, February, 1863), gives a case in confirmation. Dr. Salisbuiy 
obeervea also, that measles was not known till 1618 (Rayer) in the New 
World ; and this was the date at wliich wheat and small grains were intro- 
duced into the New World ; and monstee are most prevalent in cold weather 
— in other words, at the time straw beils are disturljed and thrashed. If 
there be anything in this view, the agency possibly must be a poison gene- 
n>t«d by the mouldy straw, of which the fungus is an evidence. 

We now come to the second great division of parasitic diseases — viz., those 
produced by the development of vegetable parasites belonging to the genus 
fungi, and named 

B. Dekhatophvtic, EpiPHytrc, oa Vegetable Parasitic Diseases, 
Or, aa I liave called tliem generically in the group, Tinew, a plan accepted 
and adopted in the new nomenclature of ttie College of Physicians. Now 
it nwy l>e expected that I should give an elaborate account of these diseases, 
but it would ocaiipy the apace of an entire book to do this satisfactorily, 
I shall therefore content myself with a practical account of the subject. 
Now fungi getting upon the surfiioe may or may not floiirish. When the 
soil is suited to their growth, they produce moat definite lesions, perfectly 
cbarnctoristic, especially on hairy parts. The same fimgl invade the hard 
structures of a very large number of the lower forma of animal life, and 
attack parts — the hiur, nails, and epidermis — analogically the same as those 



Nothing but the ravages of a fungus -can produce the peculiai* changes 
which we see in the hairs and epithelial tissue in the tinute. I do not 
know the disease in which fungi are present, and in which the hairs are 
loosened and rendered dry and brittle, or in which the epithelial cells are 
affected in such a way as to give rise to such a condition as that observed 
in chloaama. 



20S PASAsma diseases. 

Fungi arc found acciilentally ui very ninny diseases, but tliP one actjun 
they have jieculiarly tlielr own is to attack the hair or the nail, luxtuiktitig 
in it, abBorbiiig to themselves its moisture, rendering it dry aiid brittle, 
and by their growth helping to break it up more or leas. Where tLet« on 
few, praoticallj no hoii-s, then tEie growth of the fungus actjs as a local 
irritant, invades the epithelial ceJIa however in a diantcteristic mawier, and 
in eonsequence of the centrifugal growth of the mycelium, the eruptiTe 
patch is generally circular in forut. As to tlie relation, then, of parasite 
and eruption ; tlie latter is not necessarily a part of parasitic dtaeaae (*■ 
seen in tinea tonsurans, one of the varieties), but may arise as a cona»- 
queiice of the local irritation set up by the fuiigi in common with other 
agents acting from without upon a, surface predisposed to erupt. 1 repeat 
that the characteristic effects of tinea, the damaged haira and epithelium, 
are never produced by au eruption per ge. Fungi will not flourish on a 
healthy surface, but grow upon tliose that are most prone to uon^spedfic 
eruption ; and for this reason vegetable parasitic diseases occur in young 
life, diminisliing rapidly into frequency as adolescence advances ; the least 
expressed form, tinea decalvans, being most common iu adult life. W« see 
then, as stated at the opening of the chapter, that parasitic diueuse couaistc 
of a suitable soil, the fiingi growing upon it, and the effects of such growth 
— i.e., the pathological lesion of the hairs and epithelium. 

What are the fungi like ? I speak now generally, reserving the ileaet^ 
tiou of individual parasites to he included in the several diseases in nhkh 
they are found. They are trft«a made up of minute cells alone, but aa a 
rule of — 

1. Sporea. — These are round or oval, having an average Biae of ,0OC ""?■, 
but vary much : solitary or arranged in rows which are single or mtuiy Bled, 
or collected together in groxips of varying sizes. The spores oftan show a 
dark spot, an actual nucleus, or granular nuclei, in their interior. They 
are double contoured, oft«n constricted, and the halves may be unequal of 

2. Chain* of the sane spore, whieh have a vuyre or less headeti appearanet. 
— There is a real union between the oomponent cells, and the rows an mo- 
nilifom, or multiple, and branch in various directions. These forms usual- 
ly receive the name of aporidia, or Bporule-bcarers. Within them are found, 
clear contents, or granules, or, if large, eporulea. 

3. Threads (niyce/ium) of ttwy narious shapes and siaes. — Tlie least ««■ 
pressed form is that of a fine transjiarent filament, and there are stiiges be- 
tween this and large doubly-contom-ed tubes. The contents are usually 
grannies and cells. The tubes are often not uniform in diameter, being 
more or leas constricted, and tho interior space is partitioned by scpt^ 
The filaments sometimes interlace in a very free manner, and may bsa r, h 
rare instances, at their extremities various forms of fructification, «itfe 
enlai^d terminal solitary cell or a shortly jointed tube, or 
spores, seated upon a receptacle, or a radiate arrangcmfoit of g 
These tubes and threads are called thallus-fibrila. 



VEGETABLE PAKABITIC DISEASES. 209 

4. Stroma. — ^This consists of an infinite number of minute cells, and is 
the early condition or nuclear form of the fully developed fungus, accompa- 
nies all fungi in a state of active growth, and is oftentimes well seen in tinea 
favosa. It is generally overlooked, and requires a high power for its detec- 
tion. It is very potent for evil. 

The structure of the spore is very simple. It has an outer coat or en- 
velope composed of cellulose, and an inner one, or utricule, enclosing a 
liquid which contains floating granules, and is colored blue by iodine. 

These spores may be confounded with many other cells. With fat glo- 
bules, blood discs, coq)uscles of various fluids, young epithelial cells, or 
rather nuclei, pus, and earthy particles. The eflect of reagents will, how- 
ever, prevent en*or. The spores are unafiected by ether, chloroform, and 
spirit of wine, which dissolve fatty cells, and render epithelial tissues trans- 
parent. • Ammonia renders the spores a little more colorless perhaps, 
whilst it dissolves pus and the secretion of many eruptive diseases (which 
contain small granules and cells somewhat resembling large spores) '' con- 
verting them into a gelatinous mass.^^ Impetiginous crusts, fat, pus globules, 
hair, and epithelium are dissolved when heated in a hot solution of potash, 
especially if a little alcohol is added. 

The greatest care must be taken on eveiy occasion to distinguish between 
fatty cells and spores, and diflused molecular fat and sporules or the nuclear 
form of fungus ; indeed this is the important practical point requiring atten- 
tion clinically, and really it is a difficult thing oftentimes fairly to get rid of the 
fatty matter. If we suspect the presence of much fat, it is advisable to al^ 
low the hair or other object to 9oak for same time in ether if any doubt ex- 
ists as to the nature of any particles, cells, or granules. Tlie fat-cells always 
exhibit a wide variation as regards size, and have a duller aspect ; the cells 
of the fungus, on the other hand, are uuifoim in size in any particular case^ 
refract tlie light very perfectly, and their outline is more defined and con- 
toured ; they are not aflected by ether. In old-standuig cases of tinea, the 
epithelial cells take on a kind of fatty degeneration, and look very like cells 
invaded by sporules. When the mycelium is well developed no mistake can 
well arise, but thei*e are one or two foreign matters and modifications of 
normal structure that ofler appearances similar in aspect to some of the less 
flourishing examples of mycelial threads. I have known the fibres from 
handkerchiefs or towels which have been used to cleanse the object-glass to 
he recognized as mycelial filaments. Sometimes some of the fibres of the 
hair will be stripped of the shaft and curl back like mycelium. The edges of 
cells are dark, and never have a clear central line, do not braucli, and do not 
contain granules. The safeguard is to get the mycelium free from surround^ 
ings, and then no error can arise. The imbrication of the epithelium is 
sometimes irregular, and the edges of the scales present exactly the appear- 
ance of mycelium running transversely through and across the sliafb of the 
hair, and it is really difficult to imagine that filaments are not present, more 
especially if there happen to be a few sporules scattered throughout the iu^ 
U 



SIO PABASmO DI8EA8Sa. 

terior of the hair. By earefiil observation tbe outlines of tbe cells i 
traced not only over, but beyond the area of the hair. 

In exnmining for the fungus, extract a hair from a diaeased i>&tch, End 
place it at once in e. little diluted liquor potivsea* (to render the parts trrnn*- 
pRteut), then drop a jiieoe of tUin glaiw over it, without the umj of any 
pressure, and |)Ut it under the inicivsco|)e. Then if it be neceaHuy to ex- 
iiniine more minutely, dissect the pai-ts cai-efully with a needle. As h nile, 
hiirm is done by nibbing or sqiieezing the pi-epamtion between the two 
glusHes. To get rid of the fiitty matter, it is bust to soak the hair iu ether, 
iiud then tti wash it thoroughly ba^fore adding liquor potassw. With regnril 
to the fiirftiroceous deaquiinintioii, those scales which are aitiuited at the 
edge of the dineased patch should be selected ajtd treated in like Rianner, 
without using preseuiT, and tu Mninll an aniouat as is conrenieiit should be 
subjected to examination. 

The stromal or minute form exists in abundance very frequently, kimI ii 
not discovered ; the fibres of the hair conceal the small cells. If the bafr 
ia allowed to soak for a while iu alkalies, the cella are aeen, bdi) in mm 
weather the miniite form of fungiiH will develop in glycerine and watw ifl ft 
few doya to a recognizable size. This stromal form may he miatAken ftr 
pigment-gran II lea ; but the latter are uniform in sire, do not refntct, ud 
there is no accompanying damage to the hairs when Lhey are present, and 
with a high power granules do not ap|>ear transluoent. When in doubt, I 
am in the hnbit of employing artificial germination to assist. Tbe fotlowitig 
figure rejircsents the appcai-ance presented by the stromal form of fungui 
Fig g, after being "put up" in glycerine. On the linrt «s- 

^ amination only the faintest trace of the cellules mft 

(^^■■■^^^f present. 

^^^^^^^^^^V Ma,ny persons find the discovery of the fungi £^ 
^^^^^^^^^^V parasitic disease a difficult matter. The reasons fc^*' 
^^^^K^^^^^M their non-detection are mainly as follows : — 

»«H|h^^^ ^^•) ^""'' having too litrge a nwss under exam--— ^ 
nation. Thin aeotions or layers of epitheliuia or tia^0 
should be taken. (2.) The nou-UKe of reagents to render the sitspectff^™ 
tisKuea more or less trouKparent. (3.) Too much manipulation. Iu th^^ 
way spores are sometimes rolled up, as it were, in epithelial Uycrs Hufbftii!' '^ 
and altered by reiigents, and thus concealed. (4.) The presence of pignok^* 
in large quantity. (5.) Ill selection of hairs and scales. We may {tosaU^l 
extract for examination a healthy hair which stands iu the midst nfdi^^ 
eased ones j diacHsed hairs are loosened in the follicle, and altered in textnr^^ 
dry, and brittle. ((!.) The fungus may he left behind in the follicle, tb^^ 
huir coming away without it. (7.) Secondary changes are ofl*n mlstakct^^ 
for the real disease; scales may result fi*om the inilatinn of* fungus oo*^ 
in them, but in parts near, and its absenee from the same scales is no sjg^"' 
that the parasite is not the indirect cause of the scaliness. (8.) n^^ 
stromal minute form is mostly overlooked. 



VEGETABLE PARASITIC DISEASES. 211 

For some time past the three following topics have been matters of 
special discussion and interest in regard to this subject : — 

1. The vegetable nature of parasites. It has been denied that they are 
truly vegetable. 

2. Opinions differ as to the relation of the several fungi to one another. 
Some believing that they are all variations in form of the same species ; 
others take an opposite view. 

3. As to the influence of fungi in producing disease. 

Upon the third point I have already ventured to dogmatize. In regard 
to the second, I shall only say that as far as my experience goes, and I am 
fairly entitled to express an opinion, the fungi found on man are of one and 
the same stock. Hallier's researches tend to the same conclusion. Differ- 
ences of soil account for the varied aspects. Neither the size nor shape suf- 
fices to establish any difference, for these are influenced by the amount of 
fluid pi-esent, the age of the fungus, season, and the like, very readily. I must 
refer to my other writings for further information on this particular subject. 

But students may be asked for proofs of the vegetable nature of fungi. 
Here tliey are : — 

Fvrstly, The growth and independent life of the cell structures (fungi) 
when removed from the presence and influence of all living animal sti*uctures. 
I have over and over again made the elements of these cryptogams to vege- 
tate freely in preparations put up for the purpose, and it has become a 
familiar experiment with me, although the failures — as one might ex|)ect — 
are in the great majority. 

Secondly^ The peculiar action of reagents, and especially liquor potasssp. 
As far as I know there is no animal structure that resists the action of this 
reagent in the same way that spores, sporules, and mycelia do ; they remain 
practically unchanged, and do not swell up and become indistinct as is the 
case with the other structures. Iodine, again, detects the presence of the 
primordial utricle. Other behaviors might bo mentioned, but I pass to — 

Thirdly^ The fact of the ])re8ence of ulenticcd parasitic forms in the hard 
structures of animals, and indeed vegetables, where no (epithelial) cell struc- 
tures of animal nature exist from whence the vegetable elements could 
spring. In bivalves, bi corals, foraminifei^, and a host of others, as shown 
by Miiller, Claripede, Rose, Kolliker, and many more. The examples in 
the vegetable kingdom need not be detailed. 

JfhurMy^ The want of transitional forms. You cannot trace any con- 
necting links between the fimgi forms and the normal structures. 

FiftJdy^ The fimgus elements are at first visible at the upper part of the 
hair follicle, and migrate from above downwards towards the papilla and 
root ; in other words, there is a priori evidence that the germs of the para- 
site are derived ab externo, and this is proved to be a fact by clinical obser- 
vation. If the so-called fimgus is a granular degeneration, such degeneration 
must commence where the nuclei are formed, and be abundant in the early 
developmental stages — viz., at the foimative point or papilla. Such is not the 



f 212 rAHAsmC DISEASES. 

I case. Tim earlient trace of spure, apoi-ule, or mycfiliiini, is sub-epi dermic and 

\ located just at the upper part of the follicle ; from thence the parasite mmy he 

traced downwards to the bottom, whence it finds its way to the interior of 

I •Sixtlii;/, The i-e^ults of treatment, Tlemove or destroy every i-e«ti^ of 

■ parasite, in the eai'ly stage jiarticulariy, and the disease is stopped. To nAra 

■ tbut this could alter such a thing as "grauiitar degeneration" is not ron- 
t oeirable. Pluck out a diseased liaii' ; if no e|)ore is left behind, the haii 

is healthily formed at once. Besides, there is no contii'matioii in the ch&r. 
Acter of coneomitantB, The cells at the root of the hair are bcRllhily 
formed luitii the spores increase largely or sjiecially invade the papilla. 
Tliei-e ai-e no transitions. Thei'e are healthy structures in contrast wiih the 
•fungus elements, until tlie formative apparatus is attacked. The mere 
plucking out of a hair could not so aJtdr the whole character of the nutri- 
tion as to bring hock a disease (granular degeneration) abruptly into h stale 
of health. The cause of the cell alteration is cloarly not in the cell fbniui' 
tiou primarily, but due to some superadded influence which acts fi-oiu with- 
out upon the cell nutrition. 

T/ie Mode of Entri/ of Hie Fungut into the Sj/ttem.— There in no diffi- 
culty in accounting for the access of gerniB to living bodies, for thest? geims 
are fi-eely distributed and disseminated in the air. The best illustration o£ 
this fact may be uoted in the experiments of M. Bozin ( Gazrtle JtffJ. (to 
J'aris, July 30, 1804), which cousisted in passing currents of air over th^^ 

head of a favus patient, and thence over the open mouth of a jar contain 

ing ice. The ico cooled the air, causing the deposition of moisture, in th^^* 
drops of which the achorion sporules were detected. The same thing i 
be shown by holding a moistened glass slip near the head of a patient, 
Just rubbing his scalp freely. Of course, actual contact is much more et 
tual in the implantation of germs. Let us suppose that the sporular ele — ^ 
mentH hnd their way to the human surface. How do they get beneath th^5^' 
tissues? Various ways prohabiy. The fungus elements may enter by fis — * 
Biires or natural orifices; for example, in ordinary ringworm the sporulc*^^ 
lodge themselves at the opening of the hair follicles, and presently get br-— ^ 
aealh the epithelial scales. The gi'owing mycelial thread forces itaelf be- — ^ 
neath the layers of the superficial tissues ; processes may shoot out from '^ 
the spores themselves, and enter beneath the epithelium ; the sporcx may be ^ 
enveloped and carried bodily inworda ; or enter by traumatic lesions, aa in ■* 
madura foot. In each and every instance the germs of parasites ai-e dt-riteil ' 
ab escterno and not generated gpontaneouiiy. 

There is yet one category of facts lliat needs a woi'd or two of cummf^nt 
— viz., tlie comparative pathology or the uiter- transmission of parasitio 
(vegetable) maladies. It is now admitted that the transm 
niou lingworm of the surface from animals to msm is very common. 
informed upon good atithority that this is of very fre«nient occarram 
Australia, the milkers of cows e8|feeially being largely affi.'Cted. 




VEGETABLE PARASITIC DISEASES. 213 

Gerlach has noticed it in dogs, horses, and oxen, and in man, but the sheep 
and pig seem to offer exception. Dr. Frazer {Dub. Quart, Jou/m, of Med. 
Science^ May, 1865) contributed a paper, " Remarks on a Common Heri>etic 
£pizootic Affection, and on its alleged frequent Ti*ansmission to the Human 
Subject,'^ containing cases. This gentleman quotes Mr. Brady, and Mr. 
Whitla, in reference to other instances. Dr. Fehr has noticed in Switzer- 
land the transmission from cattle to man. I can confii*m by my own ex- * 
perience the truth of these statements. Mice and cats affect man. Mice 
with favus can commimicate the disease to the cat, and the cat may give 
favus, or even tinea circinata, subsequently to the human subject. 

The Pririciples of Treatment in parasitic diseases. — First as regards the 
actual disease ; secondly,' its secondary effects — ex., baldness. The main 
aim in all cases is to remove or destroy the parasite, and as this is found in 
and around the hairs, it may be in great measure removed by what is called 
epilation — that is to say, the extraction of the hair witli tweezers en masse, 
but as the hairs are brittle, in the attempt they frequently break off, leaving 
their stumps behind, loosened, and perhaps filled with spores. This epilation 
is needed in severe cases, where the disease is deep, and it is desii-able that 
some agent should be at the same time employed to destroy the fungus in and 
about the follicles, for at the time of epilation greater access to the interior 
of the follicle may be attained. 

In slighter forms of parasitic disease, and in those which are recent — that 
is to say, where the fungus had made its way into the structures only a short 
way — the destruction of the fungus may be readily and easily secured sim- 
ply by the use of what are called parasiticides ; these will be mentioned in 
detail presently. In certain of the slighter forms, general remedies are 
scarcely needed, but in other instances, where the disease is extensive, and 
the fungus luxuriant, the constitutional condition is clearly one that is 
peculiarly fitted for the growth of parasites, and some evidence of its nature 
may be gained by enlarged glands, a pale, pasty, flabby countenance, a certain 
amount of aniemia, want of flesh, disordered bowels, and such like symptoms, 
clearly indicating that assimilation is at fault. In such cases the cure is 
expedited considerably by the use of iron, quinine, and especially cod-liver 
oil in the upper classes, and the same remedies, with cleanliness, a proper 
amount of fresh air, and an increase in the meat diet, in those lower in the 
social scale. 

Now we come to the description of the individual vegetable parasitic dis- 
eases. They are — 

1. Tinea favosa (commonly called favus). 

2. Tinea tonsurans (ordinary ringworm of the scalp). 

3. Tinea kerion (a modification of tinea tonsui*ans). 

4. Tinea circinata (ordinary ringworm of the body). 

5. Tinea sycosis (mentagra, or simply sycosis). 

6. Tinea decalvans (area, or one form of alopecia). 

7. Tinea versicolor (chloasma, or pityriasis versicolor). 



214 PARA^SmC DISEASES. 

8. Tinea tarsi. 

9. Mycetoma, or the madura foot of India. 

10. Onychia parasitica, or onychomycosis ; tliis occurs as the sole disease 
or part of the other more common forms. 
Tliere is one form of disease (myringomycosLs) occurring in the ear, caused 
by a parasitic vegetable grown, and that may as well be appended to com- 
plete the list. Eczema marginatum, so-caUed, I shall describe under the 
head of Tinea circinata. Tlieio is also a state of hair seen in the beard in 
which the fibres of the shaft are split out, the shaft looking as if two besoms 
were placed together. This I note under the head of tinea sycosis. It has 
been usual to add tinea or plica polouica, but this is only a peculiar felting 
of the hair, the result of neglect and unclcanliness, in which fungi occur 
accidentally. 

TINEA FAVOSA, OR FAVUS. 

This is a rare form of disease in England ; It is commoner in Edinbur|^. 
It commences genei-ally at about seven years of age (it may be sooner, it may 
be later), among the poorer classes of the community. It is characterized 
by the presence of little straw or sulphur-colored cupped crusts, called 
favi, surrounded by more or less redness ; these favi coalesce after a while, 
and give lise to a honf'ycomb appearance, or remain separate, hence the 
varieties favus dissemiuatus and favus di»pei*sus. The disease commences 
with the implantation of the spores of a fungus just within the follicle, and 
all that is noticed in the eai'Iy stage is an increased production of epithelial 
scales ; presently a little white sub-epidermic speck becomes visible, which. 
quickly develops into a " favus." The favus is nothing more than the 
developed fungus. As the elements of the latter grow, they collect about-* 
and in the hair-follicle ; each favus cup is pierced near its centre by a hair. 
At firet the favi are but yellow specks. As the fungus grows down— — 
wards into the follicle, the formative apparatus is interfered with ; hence ^^ 
the hair loosens, being at the same time invaded by the parasite, and ren- — 
dered brittle, opaque, and thickened. The epithelial scales are likewise in- -^ 
vaded by the fungus w^hen fairly growing. Tlie favi are sometimes sepa- — 
rate, at other times they are aggregated ; they are roundish (seated u]x>n -J 
a depression of the derma), in size about j\ to | inch in diameter, and ^ - 
to j- in depth, concave above, convex >x?low, and sometimes marked by con- 
centric lines on the upper surface ; they are composed entirely of fungus 
elements — sporeSy mycelial thredds^ and granular particles, called $trotna. If 
the scalp be entirely freed from them, it is seen to be red and tender, and 
they soon refoni^. As the disease advances the mass becomes lifter and 
more brittle, and baldness sets in. If the disease be severe the hair follicles 
are destroyed, and the scalp is red, irritable, shining, and thinned. The 
nails ofticn become invaded by the fungus, and are then thickened, rendered 
opaque, fibrous, and brittle (see Onychia parasitica). The general health of 
favus patients is said to be good ; but in all cases uncleanliness, bad food. 




TINEA TON8CKAK8. 215 

bad living, damp dwellings, Ac, have (eome or all) exerted their iuflueace ; 
there ia always a good deal of local itching. The odor of fiivuH has been 
described as like cals' urine, mice, &c. The fungus is (see Fig. 10) the 
Achoriou Schoiileinii (Link). It consists of^(n) spores, generally somewliat 
oval,^jVTr inch in diameter, -003 to -Olmin., the largest having a double euve- 
lope, being either, free, jointed, or even con- 
stricted ; (£) " filaments which are large and 
branched, more or less tortuous, containing 
generally granulea and sjiorules in their in- 
tei'ior, and on an average yjijij inch in dia^ 
meter; (c) sporophores or libres, which a 
short and straight, and bear at their e 
tremities sphores — generally four it i;i said i 
— these are not oft«n seen ; (</) stroma, 
which is made up of a number of free but 
small cells, exceedingly minute sometimes." 
Favus afTects the scalp chiefly, but it may be s 
The fungus invades the epithelial scales as well a 

I dou't know with what other disease fdviij should b3 c 
I}ia<jaoaia. — It might be confounded with a free impetigo ; but this has 
a history of dischai^ ; there are no " cupped crusts ; " tht>re is no f\jnguB ; 
and no etfects of parasitic growth, such as baldness. 

Treatment. — This consists in the exhibition of both genei'al and local 
remedies. Internally, goAd food; plenty of Eat; cod-liver oil and iron; 
together with change of air and cleanliness, must be prescribed. Locally, 
the hair slioiild be cut short; the crusts must be removed by soaking with 
hyposulphite of soda lotion, or, if preferred, sulphurous acid lotion. When 
the scalp is cleansed, each hair must be extracted one by one, and parasiti- 
cides applied at once. I prefer the bichloride of mercury lotion with 
borax — a drachm of the latter, ten to twenty grains of the former, and two 
or three ounces of water. A certaiu portion of sur&ce should be cleared 
each day, and the whole head meanwhile kept moistened with sulphurous 
acid lotion. If I want to cure a favus case, I e])ilate and apply my parasi- 
ticide myself. It takes time and is very troublesome. When the amount 
of parasite has been diminished, as ascei-tained by the microscope, it is then 
advisable to exclude the air by the free use of unguents, after a good appli- 
tion of some parasiticide : the after-baldness must be remedied by stimu- 
lation. See Formulte. 

TINEA T0N8UEANS. 

This is the ordinary " ringworm " of the scalp. It is rarely seen, except 
in children ; it is, like favus, contagious ; does not appear to be attended by 
any marked ill-health, though it is frequent in lymphatic subjects. It gen- 
erally consists of little circular patches, varying in size from one-half to 
•Bveml inches in diameter, the hairs of which look dry, withered, and as if 



916 FAKAsmo 

nibbled off at a distance of a line and a }ia]f fi'on) tlie scalp. In the fint 
instance a. lungiiB takes hold of the under surface of the epitbeliiim, juit 
withiu the follicle, and t{iiickly invadea the hair, which becomes, iu coiie»- 
quence, cliimged an deaci-ibed, and brittle. Iu the early stage tlie hair ia brat 
or twisted juat above the point of its emergeace from the fullidr, aud it ii 
at this place that l:he hair breaks off, pi-oduciog the '* gnawed " appearanoe; 
if an attempt is made to jjiill the hairs out thpy break off; at the aame time 
the oritiees of the follicles apjrear to We fringed round with little " uiicaceous " 
scales, and the surface of the diseased {wtch is the seat of uiure or lesa fur- 
furaceous dcsquaiuation. The whole patch becomes slightly devat«<l, and 
the hftir-foUiclea more prominent. The scalp may be diseoBed in one spol, 
in several places, or over its whole extent. OFtentiines a little erjtliem«- 
tous ring bounds the ctrcumference of the patch, if the lutir be exaniined, 
it will be noticed U> he bulged, of dark color, with its fibres more or ItisH 
se]iui*ateil by collections of spores, which become distinctly visible on the 



addition of a little li 
rules is ]iretly ge; 



tonsuruna (Maliiiston) or acliov: 
they arc round, -003 to -IKI? ni 
to jjijj inch, iiucleat«il, ofti 
ity in size in tl 
Tlie filaments 



the dilTnsiou of B]t»- 
favus, if any mycelial tlu'eads are i-resent, 
they mostly run parallel to the fibiM 
of the liair, and not tnuisveneljr^ . 
Baldness often results, but it is tem- 
porary as a rule. Itching is fn»i)Uentl]r 
troublesome. The foIUcle is chokeil 
with epithelial cells, and more or leas 
etfused blasteniH. Tiuea clrciuata is 
often a co-oxistence, aud tiuea ton- 
surans may result from a tinea 
cimuata that ti'avels on to the hewl 
from contiguous parts. The fuugiu 
of tiuea tonsurans is the tinchojihytoD 
Lebertdi; the spores are most numerous; 
long, by -003 to -004 mm. broud, ,Vjj 
constricted, and exhibit u great utiifurm- 
ibject : they are vnry jdentiful in the root of tin- hair, 
articulated, someAvhat undulaled, and iiossess grauultfs 




their inteiior. They are few iu number. The fungus invades not only the 
hair but the epithelial scales. See Fig. 1 1. 

J^iaffnona. — Tinea tonsurans in an early stage i-esenibles no othei' disoaae ; 
over a small circular Hpol the hairs look dry and withered, aud ai-e bent juat 
nbove their point of emergence from the follicle, and there break off; the 
broken otf liairs are L-liarHCteristic. No other disease, save a parasitic one, 
will pi-oduce them. Whenevnr, iiutn, on tho scalp, a circular patch of dls- 
ease occurs, which is somewhat scaly, and there ar« short broken off hitim, 
the microscoije will give plenty of evidence of the presence of a fungus. 

7'reatin^tt. — This oftentimes is a ^eiy tfdioua and difficult matter whni 
the disease has lasted any time before coming under treatment : whoa t 



TIHHA. TOKaraiNS. 



917 



tuigi get ilwjily iiito the follicle, the hair is brittle, and attempts at eiiila- 
ion fail. lu the earliest stage free blisiering of ? ach patch will suffice, with 
ha free use of white precipitate ointment afterwards. One plan persever- 
ugly followed is the best way to core the disease. In severe and more 
;hix>nic foi-nis, cod-liver oil, quinine, good food, and change of air are often 
teeded, and plenty of fat especially Hliuiild be eaten with the food. Locally, 
he object should bo to get away all the fi'agmentB of the diseased hairs 
odged in the follicles and full of the Kjiores. With this end in view, if tlie 
lairs do not come away with any readiness we may blistor, aTid we shall 
;hen find Uiat they will be the more easily removed, Tlie healthy liair 
dunild be cut for a little distance around the circumference of the patches, 
to that the remedies may be applied freely to prevent extension of tlie dis- 
i«se. After removing as many of the hoira us possible, 1 generally shave 
Ji« patches with a not over sharp razor, and in that way often drag out (with- 
mt ]>ain) a good many of the hairs still left in t but day by day attempts 
ihotdd be made at extraction. Meanwhile the snrfaee luay be blistered 
ifith the bichloride of mercury solution. Gi-eaae may be applied to exclude 
lir and preveut the ilisseniination of the spoi'es, and tlie whole head washed 
light and morning, and well sopped in hyposulphite of soda lotioii. Tliisjtlan 
)f eidlation uud parafiiticide application must be closely punined if success 
e to be early aud com])lete. In the medium cases, after clipping the hair olf 
rery nhort, the use of Coster's pa.>tte (iodine dissolved in colorless oil of tar), 
tpplied once or twice at intei-\-als of four or fivu days, effects a cure. Am 
natters mend it is only neceasai? to use some parasiticide ointment, the 
ivliite pracipitate, sulphur, the nitiic oxide of mercury, or borax (3ij. wl 
5 j.) Tht) latter I employ freely with snccwss. As I Hoid before, I do not 
relieve that there is wixdoiil in the multitude of remedies. But when should 
;be aae of the punudticide be stopjwd ? We must be guided here hy the 
Mcteriial uvidence of the spreading of the disease, the amount and character 
)f secretion, and eapeoialiy microscopical examination; and these remarks 
kpply in piinciple to all varieties, bnt I make them here because they are 
i{iecially fitting in the ease of tinea tonsurans. I caution my readers against 
^he v*ry natui-al aud frequent mistake, that an increased amount of secre- 
lion ia necessarily a proof of sggiiivstion of the paraeitic UisPHse. It may 
Ite the dii'eet effect of the too free employment of imtunls, anil I have on 
leveral ucca&ions seen cases iu which this was the case; the actual diwose, 
M estimated by the degree of destruction of parasite, being nil : the irri- 
lont bad destroyed the fungus, but had also produced a new featui-e; the 
mre ouly awaiting a soothing plan of treatment, Tlie external evidence of 
ipreading S]>eakB for itself. Microscopical examination is the chief guide; 
t must be frequently, carefully, and cautiously made. We are enabled hy 
it (o eadinate the amount of parasite, how deeply it has penetrated the fol- 
licle, to what extent our remedies have destroyed it, how far Natui-e is re- 
x»Tering herself, and needs any more help in the way of jtaro-iiticides. So 
is any amount of fungiis in the root of the hair, so long must 



218 PARAsrno diseases. 

we use parasiticides. When the root and follicular linings appear to be 
healtbily forming, and t]\e follicle is filled with blastematous matter (sur- 
rounding the hair shaft), free from parasitic elements^ a slightly stimulating 
or soothing plan must be substituted. No one should treat parasitic dis- 
ease except under the guidance of microscopic examination. See Formu- 
lary. 

TINEA KERION 

Is a disease which generally commences like tinea tonsurans : the fungus is 
the tiichophyton ; the glands of the skin become involved with the hair fol- 
licles, and pour out a mucoid secretion ; and then we have a form of disease 
to which Cclsus gave the term kerion, in his desciiption of it in his fifth 
book. Mr. Wilson renders Celsus thus : — " Kerion is a genus of ulcer, bo 
named by the Greeks from its resemblance to the honeycomb. There are 
two species. One is whitish, and like a furuncle in shape, but larger and 
more paiuful. When it maturates, it presents a number of foramina throu^ 
which exudes a glutinous and purulent humor ; but it never suppuratei 
thoroughly. When opened, it is found to contain more corrupt matter tium 
a l^oil, and is also more deeply rooted. It is seldom met with elsewhere 
than amongst the hair. The other kind is smaller, prominent, hard, broad^ 
greenish, pale, and more ulcerated, since the foramina correspond wit^c^ 
every individual haii*, and give exit to a glutinous palish humor of the coc^ 
sistence of honey, or resembling the juice of the mistletoe, or sometim^^ 
oil. The pain and inflammation are severe, so as in some instances to 
cite a sharp attack of fever." Mr. Wilson tioily observes that there is 
difference between these two cases except in degree. The disease may, 
fore, consist of lai*ge or several small [)atches. 

One or two more particulars may be added. Tlie disease may oommenc 
suddenly, with more or less loss of hair. The hair breaks ofiT from over 
circular area of greater or less extent, when swelling speedily follow 
The glands of the neck are sometimes enlarged, and very tender ; they ma^^^^ 
even 8up[)urate. The swellings of this keiion are tender, as I have said; bu^^ 
they also look uneven and feel boggy without there being pus present. 

Thert! can be no doubt that Celsus was quite correct and particularly foi 
tunate in the description which he gave of the disease ; and that it re] 
an unusual condition of tinea tonsurans. 

The characters of kerion are : (a) prominence ; (6) its perforation wii 
foramina — 1.0., the mouths of the hair-follicles ; (c) the outpouring oi t^ 
mucoid fluid ; (d) the non-suppuration of tlie swelling ; (<f)'tbe looseness o^* 
the hairs ; (f) the after-baldness ; (g) the presence of a fungus. 

I have lately met with several most perfect examples of kerion^ illustm-^' 
tive of the different stages of tlie disease, and as the matter is somewhat^ 
novel, I may be excused for referring somewhat in detail to it. The fint I -- 
saw at t)io i*equest of a medical friend, who was in doubt as to its nature. 
It could not be regarded as well-marked kerion, certainly, but it. was in ita 



TINEA KERION. 219 

earliest phase. It occurred in a child, who had a patch about the size of a 
five-shilling- piece ou the side of the scalp, fi*om which the hair had sudden- 
ly fallen off, the nurse having discovered it only two days before I saw it. 
The whole patch was remarkably prominent and peculiarly upraised, and this 
was seen to be due to the distention and enlargement of each individual fol- 
licle. On removing some of the haii*s from the j)atch, they were seen to be 
surrounded and infiltrated with nothing more or less than a mass of sporules 
of the trichophyton. The swelling of the whole patch in this case was so 
remarkable as to make the disease appear something quite different from the 
ordinary dry, flat patch of tinea tonsurans. In July, a boy was brought 
to me with half a dozen round prominent places on his scalp, apparently, 
at first sight, subcutaneous abscesses ; but the characters of kerion, as de- 
scribed by Celsus, were present. In a third case, the mother remarked that 
the discharge was so sticky that she could not wash it off. In each of the 
last two cases there had been constitutional disturbance of slight extent, 
and the patches which were partially bald were excessively tender. In the 
second case they varied in size from that of half a crown to double that size. 
They looked exactly like uncircumscribed, boggy, subcutaneous abscesses, 
produced by the application of irritants to the patches of tinea tonsurans. 
In all these and similar cases the hairs which here and there stud the up- 
raised and swollen patch, and those which edge it round, are broken off 
close to the surface, and, as in ordinary ringworm, filled with fungous ele- 
ments unusually luxuriant. The hairs come away very readily ; and if they 
are examined with the microscope their follicular sheath, in a more or less 
perfect condition, is often found attached ; the gum-like material also closely 
adheres to them. Pus is not very abundant. The most careful inquiry fails, 
in most cases, to detect the evidence of the application of in-itants as a cause 
of the unusual swelling and exudation. The peculiar sticky secretion is 
albuminous lymph. It seems to me that the fungus destroys the follicular 
sheath, that a large amount of irritation is set up, the glands of the hair-fol- 
licles are involved, and fluid is poured out for needed repair. This condi- 
tion may run on to threatened suppuration. In plica polonica a similar 
kind of exudation is poured out into the hair-follicle, and infiltrates even 
the hair-shaft. 

I regard the kerion, so accurately depicted as to external features by Cel- 
sus, as nothing more or less than tinea tonsurans which has become compli- 
cated by irritation, swelling and prominence of the hair-follicles, and the 
attached glands, detachment of their follicular sheaths, and exudation of 
albuminous lymph. It is a wonder that this is not a more frequent condi- 
tion in tinea tonsurans. 

" Kerion," says Mr. Wilson, " must be regarded as belonging to the same 
group as trichosis and favus ; representing, in fact, an inflammatory and 

pustular form of the same disease The phytiform disorganization 

of trichosis and favus has not as yet been discovered in keiion ; but we 
have uo doubt of its presence, and that kerion must be added to the group 



FARABTnO DtBSAeKB. 



220 

of (liseHMes of wliicli that peculiar morbid pheuonienon is the truuling char- 
acter." I am well acijuaiuted with the fungus growth in keriou; &ud in 
examining ILb Lair microscopical Ij have been surprised at the &iiioaiit of 
the firngua pi-esent. 

Eeriou is only a complicated form of tinea toiisurwis ; very little, if mtiT, 
pua ia preaeut (were pus present the fungus would not be so luxurunl); 
the dieeofle usually commoncea a.3 an exa^erat«d tiima tonsurans. Ur. 
Wilson noticeti " that it was complicated in two out of fourttien CAses by 
tinea circiiiata, and tinea tonsurans in one; whilst a brother of one of his 
patiente had the farmer affection, and a sister of another the latter." In 
one instance, keriou develojied out of tinea tonsurans. 

It seems to me very clear that unless we recognize the influence of the 
fungus which the microscope ruveals to us, we cannot treat kerion 8Uc««a8- 
fnlly ; we must trust entirely to empiricism for cure, but we may li^pen 
by chance to select a parasiticide. 

T/ie plan of Treatment that suggeste itself to the mind in the Grtit in- 
Btonctt would seem to be the employment of decidedly emollient rcmedtea — 
poultiees, and soothing ap])UcationB — to subdue the intianimatlon. fitil 
thix I believe to be uusound ; for aa in scabien complicated by aauy ud 
various eruptions, we treat the scahies, and attempt to kill the aoirus, so ib 
kerion we should attempt to destioy the vitality of the fungus as the fimfc 
step towards a cure, llie pla:i is to pull out all the hairs. This will geo^ I 
erally remove the greater portion, of the fungus, for the hair and folliculi* ^ 
lining come away together, and necessarily the spores imbedded tberei-S^' '' 
Then we may apply mild parasiticides, faicldoride of mercury solution, ^^-**l| 
carbolic acid lotion, and the disease will rapidly mend. [ 

The apjmrent severe inflammatory actiuu should not Jeter us from d- ^^ 
Btroying the true cause of mischief — the fungus. These cases ai* no ne" '^ 
acquaintances of mine, and therefore I speak with some confidence. I wou1^''t 
just remark that I am glad that it is possible to harmonize the staltrmenV -^ 
of the ancient and modem physicians, to vindicate the accuxacy of the (w^^ 
mer, and to ad<l one little iact against the doctrine of the change of tirpe >*^ 
disease. ' 

Finally, it is important to add one practical remark. I have seern thw^^^ 
cases of kerion mistaken for subcutaneous abscess (nothing more likely uic^' 
nothing to be more avoided), and accordingly the swelling has been opene^^ 
by the lancet, not, howevnr, with any good result : a troublesome son; ha^^ 
remained ; sujipuration has been induced by the entrance of the aifi 
pus has burrowed beneath the scii-lp tissues. Left to itself, ki 
but rarely to suppurute. 



Tltis is herpes circinatua, or ringworm of the bodv, and a modifictttiim cf 
tinea toiuturous. In the latter the disease occurs when the hair is pleDlifnl, 
in the formei- small and scanty j hence, the ditfereuce of aspect in t 



tutra. cihciwata. 

diiwuea is readily accounted for. Tinea circinata conaiatH generally nf little 
circular ]tatcLea of what appears to be ill-developed herpes, which becomes 
the seat of fnrfuraceoua desquamation, the scales of which are invaded by a 
fuiigna. The whole ia eomewhat elevated. The edge is often distinctly 
vesicular, and the patch inci'eaaes in area by centrifugal growth. Itching 
ia a Tery common and marked symptom. The disease is seen on the face, 
ueck, breast, and upjH-'r luiibs. It has been seen to travel upwards to the 
head, and becomes tinea toiisurans. Sometimes the centre is palish or 
clear, and a ring alone remains, and this ring moreover may be vesicular or 
jwpular. It is sometimes epidemic in public institutions, and frecjuetitly 
coexists with tinea tunsurans of the scalp. It is difBcult in some instances, 
when the scalp is the seat of mischief, U) determine whether the disease is 
tinea tonsurans or tinea circinata : the distinction is impossible sometimes. 
As I have said, the one disease gives birth to the other sometimes. The 
fungus invades the hairs (see Fig. 12) as well as the epithelial scales (see 
Fig. 13} ; it is the Iridiophytou tonturati*. In other cases all that exists is 
a little slight red ^distinctly scurfy patch ; it looks like mild eczema in its 
ecoly stage, but tJiere is no history of discharge. A little red iteliing spot 
appears, of the size, say, of a split [*u. Tliis eiJarges more or less in a cir- 
cular form, and becomes faintly Y'ur 13 Fig IS 
Bcaly, looking, [lerhapn, here and 
then) as if it were disjiosed to be 
slightly vesicular. All that re 
vultn, howevei', ia the red, more o 
less i-ound, itching, slightly scaly, 
patch. Several patches may occur 
together, about the neck, shouldci's, 
arms — we see it on the cheek in 
cases where tinea tonsurans of tlit- 
Rcalp exists at the same time. It is 
mistaken for pityriasis. Wherever 
a circular erythematous itchy patch 
appears, it should always be ex- 
amined for a parasitic cause. In 
tlie fork of the legs an erythema- 
tous rash sometimes occurs, with a 
red scaly centre, and a well-defined 
edge. It occurs in di^sgoons and slioemakera especially, and is called ecsema 
marginatum. It is really tinea circinata. Dr. Anderson has figured the 
fungus in the May number of the £</inlmrffh Me-Uad Ji»irniii (1868). 
The disease clears in the central [lart, leaving behind some Htsininir ■ it 
extends centrifugal ly ; several rings, one within the other, may l>c present. 
The disease is known also aa Birmese ringworm. The dis(<a8e has no 
history of discharge, only redness, itching, scaliness, a clearing of the centre, 
d B well-defined circular edge, and a centrifugal extensioD. 




^0 In tba epi- 




22S PAHASmC DISEASES. 

■ In some cases I have seen vesicul»tion bo distinctly marked) ex., nrer Apidcll 
of ^nea drcinata of the arm) iia to give tlte aspect of an eczema ; batint^M 
cases the fungus lias beea peculiarly well developed and very pleaitifal, uaSM 
in Figs. 14 and 15, which represent tlio most developed form of faagus I luv* 
ever seen iu this disease. This vaiiety has been well defined at it* edgt, 
clearing, imling, and desquamating at its centre, the minute hurs of tbt 
part being quit« loose and invaded by the parasite. One word of speciki 
advice under tliia liead. In cases of tinea circinata we must exatoine snffi- 
oieutly thin suctions or layers of epithelium and seek for tlie minute form lA 
fungus, otherwise we aliall very likely miss the peirssite. These modific»- 
tions noticed, depend, then, ou the luxuriance of the fungus, and the d^ree 
of irritation produced. Thediseasftmay beamei-e rednes'), or present distin^A 
vesiculation, or be somewhat papular, but in all cases it is a circular pittcli. 

The Diagtwiis. — Tinea oircinata niay be confounded with «cxeuia, leipr -* 
vulgaris, pityriasis, but it has in reality no marked genlinM», as those likt^^ 
Where the vesicular or fjuaai-herjwtio oharacter is not developed, so tu ti=3 
set the dia^osia at rest, it is fdwiiy» necessary to use the niicro9eo[>e. Tb^0 
1 in>'iirittbly [iractise. Special precautious must be taken to detect th* ha^^ 
gus; to tJiia I have before referred. 

TreiilmeiU.^ In the early stage the application of any parasiticide wiL • 
Vig. 1-1, suffice : solution of nitrate oK' 

silver 3ij. to 5 j. of spirit aVcl 
nitric ether; acetic acid; ink,.^ 
eveji; strong Imihuc lotion; hy- ^ 
poiodphite of acida lotion; 
bichloride of mercui')- lotion 
gr. ij, to 3J. ; or anitnonio- 
chloride of mercury tuntmant. 
\ But iu some tnstsnces the dis- 
ease erojis up heie and them 
over different pm'ts of the sur- 
face, and no sooner dous one 
patch fade or go but othan 
a])[iear: evideutv is obtained 
of a condition of system tli»t 
is favorable to the growth of 
the fungus, and that is nlterad 
by remedies specially nd«{>tod 
to the lymphatic leni{>nra[iMi&t, 
1. rieiit ai uix •hifu and the dilute acids and bittAix 
are given, or even arsenic, iron, ciuiuine, cod-liver oil, as the case may be, 
using (beyond the parasiticides to the xpeciidly affect«d places) aUuHiM 
baths and sponging with hyposidi>hile lotion to the parts of the akin 
around the affected area, Theiv is no inl^ninl tipeeific ; local niuii-dii-s act 
efficiently when the general heallb is satis&ctory. In eczema mtuginatua), 




B IIIBU MIi, . 



^Btluti< 



TINEA SYCOSIS. 



n of bichloride of mercury (two gi^ins of the Iftttcr to an ounce of 
ftuid) IB recommended by Dr. Anderson. Tlie dingnoeis onoe correctly made, 
the cure should be enfiy, Where the iliae-Eise is olistiimte, bliHtering with or- 
diiutry veaicating fluiil, or the line of a solution of iodine in colorlena oil of tar 
{ 3j.»d tJ.) is efficBcioua, Care must be taken that too much ij-ritstion bo 
not produced. 

TiKKA svrosis, 
Tineft-nyeosia (mentngra, or sycosis mcnti as it is called) is the next variety 
of dineaAe to notice. It is a disease of ftdult life, and what is meant by tliis 
fliseasD is an inflamniBtion of the hair-foUicles of the beard snd whiskera, 
produced by tlie jn-esence and growth of a parasite. Many (Wilson, Hebnt, 
Bimon, WcdJ, and Hntehinson) deny its parasitic nature. However, Dr. 
MoCall Anilerson and 1 are ijnite agreed upon the point; we have seen the 
iun^is in abundance present in the difleasiid subject', nndor the microscope, 
ill Charing- C'roRs Hospital, where I had the pleasure of meeting Dr. Ander- 
son. I held the parasitic nature in my jiapers originally lu Uie Lancnt, in 
1857. and I have seen no reason to alter my opinion, t eutJrely subscribe 
to the views propounded by Dr. Anderson in the JUdinhwrgh Mflicid, Jour- 
nal, for June, \mK The truth is, that thei-e is an irapetigtwons atfection 
of the follicles of the beard thnt is likt^ly to be, and is, mistaken fortKepam- 
sitie disease; hut the former haa an aci)t« onset, luid liuiks the damaged 
hail's chamct^ristic of tnie panutitic sycosis. In typical nastis of true sycosis, 
which, however,are rare, the disease coranienct-s quietly,and nins a chronic 
oonne ; in rara instances I have seen it (in persons suddenly roduced by a bad 
Mid insufficient diet) occur pretty aciit«ly, the soil having become \'(.'ry favor- 
liWe for tlie growth of the pai-asite. However, as a nile, the first thiiig uoiiced 
is a. rtd itchy patch, which is really tinea circinata, coucetJed by the Imir. 
After a while, ns the fungus gets into and down the follic)os,tbe Utter iiiAaine, 
enlarge, anil pustulate ; subsequently indnnition takes place Droiind the fol- 
licles, and shaving is pain- Fig, 10. Tig. 17.' 
ta\ ; there is also a slight 
burning sensation pi'esent. 
Snccessive crops of pusdilpK 
appear often gi-ou|ied to- 
gether: and crusting t^i a. 
limited degree occurs. Re- 
missions are noticed in 
spring and summer. It 
is clear that the liair-fol- 
licles are the seat of the 
disease, and the liatrs tliom- 
wlves bcciime altered, geN 
ting dull, brittle, and loos- 
ened in (he follicle, so that 
they are removed with case. 




224 PARASITIC DISEABES. 

but not iu all tlie iaflaroed follicles, because the original in^^'^' 
by tli« [iara«ite in one is ])ro|jaguteil to another through coi^^*- 
It niiiiit uIho be remembered that pus is a parasiticide to ^^^^''^ 
Tinea circinata sometimes coexists. T!ie fungus of sycosis ^j ^ — -* 
17) is called Microsporon nt^ilagrophytet. The sporea a^^^^ 
nun. i-oiinil, anil more or less nucleated ; in fact, they are m "^^^ 
the trieh<nihjton. The mycelial threads are said to bo bram- ^^^ 
of W to W, and to be annulated. The fungus is itaid to \w -^^^^ 
seat outside and aroimd the hwr. This ia not abeolutely tn*^^^ 
But there is a variety of sycosiB wliich I now describe for ^^^ 
The litiirs of the beard are noticed to be bent at one or mor^ ^ 
shaft, and at these bends what appear bo be little white knots af^' 
knots, however, may be seated at any part of the shaft, WTi ^^ 
bnished it breaks off. This oondition is seen in the beard an^ 
adoloHCcnts and middle-aged men. On placing a " knot" onde^ 
Bco]H>, it is seen at once that the fibres of the hair are se|tarate^*^ 
forming a little brush-like rim all round the shaft. On carefd' 
fungus elements are seen upon and between the frayed out fibr' 
PI |g minute form in the ahafl its< 

hair can often be split up int^ 
, three bande, after the additic 
alkali. The figure 18 will ra» 
plain this condition. I have i 
free end of the hair present a 
like ap[>earance. It is due to i 
getting into the root and de^ 
in the shaft after being carrii 
distance along it, 
I>iii[fao*ia of J'anuntir SyeOfi*. — It can only be confounded with 1 
menii and acne : the first is more suiwrficial, oft«n acute, has more c 
the hnira iu tt are not loosened, but cause i>aiii in extraction. In | 
svisuiis, the origin from an itchy, scaty s]>ot, the induration of the : 
sIhUs, the absence of frt-e enisling, the looseness of the hairs, and 
acurt' tif the fiingiiR, as slio«-n by the microacoiie, are distinctive. 
th« U'anl n-scmblcs tinea syctvus. Other acne spots exist on the pi 
frum haint or elsfwhere ; the liairs arc not disorganized, though the} 
Miuu'what ktoscned, and there is an entire absence of parasite or it 
on the faair^hnft. 8y)thilitic disease is known by its concomitanta. 
TivatmrnI oi'>usists of epilation and the use of a fiantsilicide, the a> 
i-^ »iininhitin^ ftHwl ami drink. The treatment in bcl is the same 
tonsurans. S^-e Vonuulw — rarwitioa) ivwedics. 

TINKA DBi'ALVAXS. 

Tint's dci^alvaiis, aloiiecia arwtmscripta, or area; these are tht 
givvuio a dist'ade which is •:ha^tl.-1<^rized by the presence of circuUr,! 




226 



FABABrnO DISBABEB. 



iiiBtaiiceB til ere ia 
are invisible, parti 



ilwaye tLini 
:ipAttIig thei 




ing of the entire denna ; tlie Iisir-fciUiclM 
iselves in tlie general atrojiLy; the sensibil- 
ity ia (liiuiuished, bo tliat tLe np|>lic&tiaii 
of strong vesicHting tluidti Ecarcel^v ini- 
tates the scalp if it does sg at all, Tlitre 
in a geuerul tliinning of the liair .luring 
the progress of tiie baldnes»«, and oflen 
Liitecedeiit neuralgia or some d^nitv im- 
\ puirnieatA of nutritive power tiiiccalde lo 
a efficieut cause, and no paruaitv to he 
I found. On the otlier hand, in the |tM»- 
sitic form, the hair-folliclea are viaiblti 
there is not any diminution of seiisibiii^ 
e than ia due to the inactivity of tks 
follicles, and there is oft«u antecedort 
erythema, with concomitant iii iiTjiiiw 
over tlie bald patch, whilst the loss of hair is in strong contrast to ft vigar* 
0U8 growth often of dark black hair around, on a head with a good cn^ of 
hair. I am quite clear as to the parasitic form. It is sometimua cont4i^oii»-. 
A remarkable ease in point was afforded at Hanwell a few years si 
where the disease spread from one to between thirty and forty children 
the snme part of the building ; the onUnary fungus wwt detocteil in tliev^Mii 
cases, which are alone expluined by the contjtgioua nature of the HiaoBawnW 
There are also tranaitionut stages between the pui-Bfiltic variety and tine^^^ 
tonsurans — the two may exist on the same subject even (see BnlUh .Ve(/i^H>4 
rai Joumid, Feh. 29, 1868). I think, then, that circuniscrilied ball 
may certainly be parasitic ; but, moreover, it may be non -parasitic, and 
a ]iart of an atrophy which affects the entire thickness of the skin. ITie 
portaiit point to recollect is the stromal form of fungus present. A lo< 
baldness aa well as general thinning may be produced by syphilis. 
The Diaffiiosis I have given in the above remarks sufficiently i 
7'/i« JVeatmerit. — I may aa well speak of the non-parasitic liere so 
to say that the general treatment consists in the exhibition of ihoau 
ular drugs that tone up tlie nervous syat«m, such as strychnine, largo iloaoc 
of dilute nitric acid, iJ:c. Locally, the use of iodine paint Iwilv a week, 
continued for some time, and tlien free stimulation with cautliarldes, are 
the hp^t remedies. A host of ]ianaceas have been suggested, but I ratinot 
mention these here. As to tlie parasitia form, my plan is to blister ftU 
patches that are on the increase with blistering fluid — twice or more — to 
pull out a few of the hairs around the patch, then to nib in for some liUla 
time bichloride of mercury ointment (gr. ij. — v. to 2,i.), and finally, to. 
ttlate with nux vomica, cantharides ointment or lotion ; and 
ranee I scarcely ever fail in my object. 1 give ii-on, cod-liver 
otlier drug, aa the special nature of ea<!h cast may require. 



m— ^ 



looJuidHj 

«pi3^ 



Lnd by panM|gJ 
r oil, bitt^^^^H 



228 PABAsrno diseases. 

SypMUtic stains. ChJoauna, 

5. Absence of itching as a rule. 6. Itching troublesome, inoreased bj 

warmth. 

6. Circular form of the stains, varying in 6. Patches generally of irregular shape, 

size from that of a f onrpenny to often of large size after the disease 

that of a two-shilling piece. has existed for a while. 

7. Desquamation absent. 7. Desquamation usual ; branny acalca 

can always be scraped away. 

8. No elevation. 8. Slightly elevated. 

9. Other forms of secondary disease 9. Eruption uniform. 

often present. 
10. No parasitic elements found. 10. Parasitic elements easily and always 

detected. 

Chloasma may occur in men who have had syphilis, and with some fre^ 
queucy perhaps ; but that is readily explained by a special process of con. — 
tact. Leucoderma may resemble chloasma, but there is no desquamatioK^^ 
and lio parasite, as there must be if the extensive staining were parasitic. 

Tfeatinenl. — 1 have one mode, and it is always successfuL I apply ^^ 
weak alkaline solution, first of all, or wash with yellow soap, then spon gt^ 
with a little weak vinegar and water, and apply freely a lotion composed oir ^ 
four drachms of hyposulphite of soda and six ounces of water. A hjrposul-- -^ 
phite bath once or twice, if the cure be obstinate, will aid somewhat ; but l^C 
never require much else than this for any case. 

TuiiM tarsi comes under the notice of the ophthalmic surgeon; bat it ^ 
may be as well to say that the inflammatory state of the Meibomian gbmds ^ 
fi\Hjuently seems to dej)end upon the presence of the trichophytoiL The -^ 
fungus is the trichophyton. 

MADrRA FOOT. 

The Miuiurajooty I^unffu^ /oot of India ^ or Mycetoma, — ^The characten 
of this liisease can only be summarized here. The malady depends upon 
the presk'noo of a (iarH:site which makes its way beneath the integmnents 
mostly of the foot to the bones, producing symptoms closely resembling 
cariecu There are numerous sinuses leading to the diseased bone, and giv- 
ing exit to fungous elements in the form of little black, white, or red iDfos, 
together with thin sero-puruleut or viscid secretion. Mr. Minaa, in the 
Indian Me^fictti iwiiiett^ for May 1, 18(>^, describes and figorea the disaaiwr 
(as attacking the hand and the foot). It began in one case as a blue ^x>t 
on the |ialmar surface near the index finger. In a year a fistula formed on 
the dorsum, and the hand enlargetl generally ^ith intense pain. I bare 
taken the liberty of giving a copy of one of his repivsmtations. See ^g. 
23, of a diseased foot. If an examination of the structures of the foot be 
made, we find them studdeii with little masses of \-arTing size, which may 
be black, rvd,or white, and which may be |ucke\l out f rom apparoit eavities 
lineal by a s}ieoial membrane. The litUe pics containing these may be atn- 
ated in the bone, and aiv caused by sim^de absorption. The joinU are 



229 



iic3cril>es the appearance of 
Fig. 33. 




healthy, and no true caries exista. Dr. Ey: 
the soft ]iiLrts as compOHed of "nuuei'oua 
niinute tubercles nssemblmg fish-roe lying 
beneath the muBclos, and extendiug from 
the bones to beneath the skin, and nodules 
couiiK>tied of the same, often black in color." 
These latter often surround the apertures 
of the sinuses on the surface. In addition 
to tlii<iie elements, there is more or less fleshy 
substance infiltrated amODgnt the tissues, together with fat aud sloughy 
matter ; the general health remains good for a long time ; but after a while 
the pain debilitates ; when the disease is removed by amputation the patient's 
debilitated condition rapidly improves. The fungus is the diionyphe Car- 
teri (Berkeley). Dr. C'liiter says in the early stage there are little elevations 
which burst and discbarge a thin yellowish purifomi fluid containing gran- 
ules like poppy-seeds, the skin being thickened 0:1 the plantar surface, and 
knotty here, and thei'e. Mr. Moore of Rajpootona sayn it apjiearn as a 
nodular swelling, presenting black particles beneath the int#guiueut as if 
gunpowder or Indian ink had been pricked into the foot. Tlie fungus occurs 
in masses, varying in size from that of a [lin's head to tliat of a bullet. As 
before observed, tliey are black, white, or red. The black variety, brown 
within, and having a radiated aspect on section, is made up of tubular, 
cylindrical, knotted threads, radiating in every direction, and terminating 
in globular dilatations ^^, inch iu diameter, the fibres being about ^g'^^ inch 
in diameter; they may be beaded. The amalleMt mosses are a mere packing 
together of these globular dilatations. In addition there are scatt^i-ed 
aiuongst the fibres: oval, clear, thick-walled cells, from 3-$'^; to T^g inch in 
diameter, which give off prolongations; granules: fatty matter: and a 
framen'ork of fibres. The (fijAi-colored variety occurs in Kmaller masses 
than the black variety, and is composed of the same elements — viz., beaded 
fibres, compound or simple cells of pinkish hue oftentimes, which can be 
Been when aggregated, by the unaided eye ; they ai-e very numerous, and oil 
examination the cells appear to be often quadruple, double, triple, or 
cuboid; there are also some little bi'ownish masses like poppy-seeds. Tlie 
two chief forma, then, in Chionyphe Cni'teri are, " cylindrical articulated 
threads," ending " in large spore-like cells," and brood filled with daughter- 
cells. The latter are often dotted externally with a radiating giowth assum- 
ing a variety of forms, which, as I have remarked elsewhere, is proljably 
produced by the crystallization of fatty matter. Mr. Berkeley believes the 
Chionyphe Cai-feri to be closely allied to the genus Muror, but differs in 
the absence of the columella in the sporangium. Fig. 24 and descriptions, 
which are Dr. Carter's, sufficiently indicate the charactei-s of tlie Chionyphe. 
It is stated that paitial amputation and the use of acids or strong parasiti- 
(JdeH are aucceasfuJ in aiTesting the disease. 



1 



FABASmC DI8RASSB. 
PLIL'A POLOS I CA, 

This may soon be di.smiasuil, Thk diaease is produced IbyS 
together of thu hair^ sulisei^ueiit iuJlaiiiiiiatioii of the hair-folliclc», tlie iiifil- 
tmtiuii of the hair witli blaoteiiiatous fluid, the asueinhlage of [ledicuti, and 
the presence of some few vegetable Npurett. It ia iii reality f^ltiiig product 
by nej^lect, I must refovto my ^vo^k on (laraaitic diseases for further in- 
forraation. 




Pi?. S4.— After Be>le, from a drawing \)j Cuter. 

blf h KTFw i>n Ihv Kiirruv M ths fliiid mtciinii tha portl'mB of ■ foot aSBOtad 
AniUtail to ^bow jlk ilav^Lk'pment fnvai tliF ^ormlDAUiig Pt«riilia» a, a, d, ki tl 
r lh» •vanf. 
uttw HiArldljk A, ^ bp CaumwtHntinit of *pore.dellH c 



OKVCHIA PAftAEITICA. 

This disease, called also onycomycosis, or parasitic disease of the nsila, t»- 
quireH a few words. 

Now, in any of the tinea of the head, espetiially favas, the nails nu^ be 
attacked by the fiiugiia present. It acts upon the nail in tlie same manntf 
that it doos on the hair; it tliickena and dries it, destroys its polish, reniJen 
it brittle, and the [jarasite can be seen growing into and amongitt the com- 
ponent elempnts of the nail. I may an well relate the cases by Dr. Paraer 
reeorded in the Dublin QuarUvly Jonrmd, for NoTeuiber, 1865. Hegirw 
two OHsas. The first is shortly as follows : — Nail dirty bi-own, ■ 



ONYCHIA PARASITICA. 231 

with lines of a darker color, gi-eatly thickened, and at its free extremity sep- 
arated from its bed by a mass of sofb^nail-substance which could easily be 
picked out. The entire nail was somewhat roof-shaped, a prominent ridge 
running along its centre ; its surface was uneven and titiversed by rough 
lines ; longitudinal stri» well marked ; the nail had a tendency to split up ; 
and the microscopic appearances of a bit of the nail were as follows : — (1) 
spores like those of trichophyton ; (2) filaments tortuous and branching, 
jointed and containing nuclei ; (3) larger, less branched, bi*owni8h filaments, 
containing spores, walls of many indistinct-looking like moniliform chains; 
(4) giunular matter. In the second case the appearance of puccinia was simu- 
lated. Dr. Purser describes the fungus as trichophyton, and by his courtesy 
I am enabled to give a figure of one of the specimens (see Fig. 25). In the 
Report of the Clinical Society of London for the 13th March, 1868, the fol- 
lowing occurs in refei-ence to the achorion (favus parasite) attacking the nail : 
^^ Dr. Hilton Fagge exhibited three patients affected with parasitic disease 
of the nails. These cases were re- Fig. 25. 

markable not only on account of 
the rarity of such affections, but 
also because that they liad an im- 
portant bearing on the question of 
identity or non-identity of the vege- 
table parasites which attach to the 
skin. The first case was that of a 
child aged eleven, who had for some 
years suffered from favus in a very 
severe form, affecting the head and 
limbs. The disease of the nail — of the left little finger — ^however, had only 
commenced about three weeks before she came under observation. There 
was, therefore, an unusually good opportunity of observing the course of the 
affection. The tubes and spores of the fungus were seen to penetrate the 
substance of the nail, gradually invading it till they reached its i*oot. The 
lamina of the nail then became loose. The progress of the disease thus dif- 
fered entirely from the description given by Bazin, and English winters who 
had followed him, according to which description a favus-cup forms beneath 
the nail, and gradually perforates it. The affected part of the nail was 
of a sulphur-like color, and when the lamina had been removed the 
bed remained covered with an irregular striated mass of nail-substance 
of a yellow or a brownish hue. This appearance was precisely that 
of the diseased nails on the other two children, and on microscopic exami- 
nation they too were found to present sporules and beaded tubes as of 
achorion. Yet these two children, who were sisters, displayed no cups nor 
masses of favus on the scalp or other part^ of the body. Dr. Fagge en- 
tered into some further details respecting these cases, from which he stated 
he was led to regard them as affording strong confiimation of the view 
maintaiQed by Hebra and by Dr. Tilbury Fox that the fungi found in the 




232 PABASmC DISEASES. 

different forms of favus are in reality mere varieties of one microsoopie 
plant." 

A less severe form of similar changes may be produced by the microsporan 
Audouini (tinea decalvans). 

llie Diagnosis must be made from [Psoriasis and syphilitic onychia. Sus- 
picion is aroiised by concomitant pamsitic disease of the head, and the 
microscopic detection of the parasite is conclusive. 

TreutinenL — The nail should be removed if the disease is deep and exten- 
sive. If superficial, scraping away the lamina is needed, and strong cai-bolio 
acid lotion perse veringly used, or glycerine and hyposulphite of soda lotion, 
will be the best remedies. 

MYRINGOMYC08I8. 

Another disease to note under this section is one caused by the growth 
of a fungus within the meatus of the ear. It has been re-described by Wre- 
den lately, in the ^* Comptes Kendus," August 26th, 1867, and named 
myringomycosis or mycomyringitis — oiitlandish terms both of them. Hie 
fungus is the aspergillus nigrescens and flavescens, having all the characterB 
of a glaucus, save in color, or an ascophora elegans. In four out of 
cases, Wi*edeu foimd the disease on botli sides. There was much 
ment of the function of ht^aiing and a good deal of irritation. The 
tends to form an interlaced mass of fibres or rather a white whining tisaui 
studdfd liere and tliore with black i)oints (aspergillus nigrescens), or 
ish V'.'llow (A. fiavescons). The injection of a weak solution of hypochlorid^ 
of lime or arsenite of potash is recommended by Wreden. The same 
thority suggests that the source of these moulds may be the walls o: 
uncleansod antl stuffy rooms. Lastly, in pruritic irritation of the vi 
oidial forms of fungus may be present as the cause. This has been called 
vaijiiuil mi/i'Vitiji, A parasiticide at once stops and cures completely the pru- 
ritus, wliich otherwise miglit be troublesome. Anal irritation in obi 
after thnibh may arise from a similar cause. 




234 KEiTBOSES or the bkix. 

to brain and spinal diseaties ; occasionally it is idiopathic, and when Uiii b 
tlie case, it partakes of the nature of a ueurulgia, or in liyRtericul Id origiiL 
Tlie xkin is morbidly sonsitive to all iiupressio&s, the clothes, the air, pret- 
Bure, even that of lying. 

Auwathesia is a secondary symjitom of other diseasea, each at 
atrophia cutis, and 1 name it liei-e for the sake of completeness. 



This dUvHite is choracteriaed by the occurrence of what is termed " 
ing." This may coexist with, or be entirely unaccompanied by, chanfje «l 
atnictiire. The word pruritus ia generally used in common ]Mi'latiee 10 
signify itching, whensoever and wheresoever it occui's. As a aeouiuUry 
disease, it is produceil by gstierai' eatuea — e.ff., tlie rheumatic diatbeaia, Uu 
circulation of morbid elements, as bile, excreta; by aJteraliuus of tempen- 
turc, gasti'o-intestinal diaturluuice, nervous diseases, genitu-ui-iuory utd 
uterine deiungeiuents, sedentary habits, rich stimulaliiig diet; by Uieal 
causes — ascaiides, piles, parasites (animal or vegetable); by vaiiou^i skin 
eruptions, esjiecially lichen, prurigo, psoriasis (in its early atageii), uoeoUi 
When pruritus is spoken of in the abstract, itching, as conslituting the 
primary and sole disease present, is signified, and the nervous cbaraoter of 
the itching is frequently shown by its sudden Sjipcarance, its almost at 
sudden dixappearance, and often its marked tendency to periodicity, 

Pruritus may be general or local, and it itt very usually followed by fteocu.- 
dary changes in the skin. When general it may be due to an inactive Btat« 
of the skin, by which the nerves are ii-rltated, or it may arise from reflex 
irritHtion, The local forms ai-e the most important. They are P. aui, P. 
sci-oti, P. piidendi, P. pneputii, P. urethrw. 

Pruritus prwputii is merely itching of the glans, connected with an Ab- 
normal secretion of sebaceous m&tter by the follicles there. Pruritus ore- 
thrn is itcliiug connected with disease of the bladder. But in P. aui, acrott^ 
and pudendolis, we hare marked itching as a primary feature with secouiiu]r 
ei'uption, and other changes, such as discoloration of tlie skin, exoori«tion| 
etc. These are the features of jiinirigo, and thert;forc thcoe l)ire«* vtuiuties 
of pi-uritua sliould really be regarded aa local prurigos. I shail describa 
them nccoi-diugly ue audi; these local varieties are often as troublesome sa 
the general disease. 



I have read with very considerable i-egret that which has Ixx-n expresssd 
in England of late in regard to this disease. The leudiikg dcrinatologista an 
agreed on clinical grounds that the neurotic character of the disease is suffl- 
ciently maiked to classify it luider the head of neuroses of the skin. SioM 
the intoose itching is often the sole as it is the primary and imponout thing 
present — other phenomena observed iu the skin are secondary. 

Prurigo is a disease of advanced life. When fully developed it i* fli 



'»«jjy| 



PRCEioo. '2'65 

aeterizpd by tliree sets of aymptonis;— («) intense pruritiiB, ivLicli is iii- 
creasni hy Lfat of all kinds, the warmtli of tlio clothes, and is generally 
desoribed as a ci-ei-piug sensation, such as wotild be caused by a multitude 
of insects ; (i) b jieculiai" unhealthy, yellowish, intiltraled, but yet wiinlcled 
and flibby state of skin ; (c) the presenco of (laputes, wbich are not pi-omi- 
nrnl, but (latt«nod more or less, disscmiuated, and showiiig at the summit 
of each a black speck, caused by the diyiiig of a drop of blood, which is 
t^ffusud in consequence of scratohing. The pruritus is j>eculiar ; it ix burn- 
ing, cri-eping, tingling. Friction aggravatcB it, and yet the jtatient tearn the 
akin with liis nails, and thus indnfes secondary chnngi« (erythema, pustides, 
wheals, and iilcerationB) ; and a peculiaj- TTMun-urtication is frequently seen, 
and produced by esaggerution of the little areas of skin enclosed by the 
natnrnl fiiiTOWB, These ai-e the broad papula' of prorigo. lu addition, the 
skin becoues more or less pigmented in chronic cases. Prurigo may be par- 
tial or genei-al ; it occurs generally about the back and outer aspect aS tlie 
limbs ; about the shoulders, the clavicles, and the belly ; it is often localized 
to the rniiiH or genital organs. The pruritus niuy cause aleeplessnoas, toss of 
■[^tite, and a condition of general discomfort and misery. 

Now in hoN]iital practice especially, iii connection witli these changes, 
pedicuU ai-e observed. Thb is a very old fact indeed; and it haa been 
theuc« concluded that jiediculi are always the cause of prurigo. Clisically 
thin is not true. Prurigo, as I have described it, may exist without the 
veslage of a pediciilus, as an essentially neurotic disease. It is not common 
to have prurigo without lice in uncleanly ))ersons, iii hospital pi-actioe ; bnt 
to say tliat every man who has prurigo is " lousy" is not a fact. 

Neligau, speaking of prurigo in old ])eople, says — " tlio chief peculiarity, 
however, in prurigo senilis in that it in invariably attended with the appeur- 
Aitoo of innumerable pediculi ; " and he stjks this " a complicatiou never oXt- 
sent in the [Mjor and in [lersons of filthy babits. Their prcaenca ug^ravat«s 
the other symptoms," Tliis form is often called pi-urigo {tedicularis. The 
relation between the two I will sjieak of directly. The varieties of prurigo 
are — J'ruTtffo mitig,farinicang, and eenilU, with local varieties before referred 
to under the head of pruritus, 

Pruriijo mitts is the least exjiressed form of the disease ; occuiti in sum- 
tner, about the back, the outer [tart of the limbs and shoulders, un<ler the 
clavicles, and about the thighs. It is seen in the young sometimes ; the 
akin after a while becomes muddy and tliick. 

Prvrigo foTvpeani is a more severe form of disease, and attacks eldei-ly 
pwple : the main peculiarity is in the sensation, which is that of the creep- 
ing of innumerable insects over (be skin, «iccom|ianied by a burning feeling 
tiwt keeps the patient awake, and distresews him, Scratching gives rise to 
postnlatious, witli subsequent discoloration of the skin. The eruption ia 
pretty general. 

J'ruriffo »cTti/ia is the fully-developed disease as I have described it, and 
■■■■bis form ]K:diculi aiv mostly present in uncleanly people; they are found 



236 NEUBOSES OF THE SKIN. 

in the folds of linen, especially about the armpits, and require to be care- 
fully looked after for detection. Contrasting those cases in which pediculi 
occur with those in which they do not, we notice ^^ louse-bites ^' in the former 
and not in the other. The louse-bite being a flat, at first palish elevation, 
with a central dark spot where the wound has been inflicted. These have 
long been recognized. 

Local Varieties, — In these the papules are not very numerous, but the 
pruritus is oftentimes terrible. ^. podicis is seen about the anus, chiefly of 
adults, and is sometimes produced by irritation from ascarides : it attacks 
sedentary people, or those who suffer from hemorrhoids ; papulte of charac- 
teristic asi)ect are seen, the skin gets thickened, and in consequence of the 
contiguity to the mucous surface, gives out a moist discharge. JP. scroti ia 
the same disease in pother situation. In consequence of the moist secretion 
and excoriation, an eczema is simulated. In ^. pudendalis the redness of 
the mucous surfaces of the vuIvib and vagina is accompanied by paroxysmal 
pi-urituB of burning and distressing kind ; the parts swell, the sur&ce dis- 
charges, and the acridity of the fluid causes redness (intertrigo) of the sur- 
face outside the i)assage ; nymphomania is induced, and occasionally papules 
are detected. 

Besides these varieties, there are some mixed forms of disease. Prurigo 
often complicates scabies ; in which case the papul» of prurigo are noticed, 
scattered over the forearm, the abdomen, and thighs — ^not on the iajce : this 
may be called scabies pruriginosa. Strophulus pnuiginosus and pemphigoi 
pruriginosus occur, and have been described. 

Pathology and Catise. — The basis of the disease is a paresLs, a disorder of 
the nervous element of the skin — a neurose. This disorder is brought about 
in young people by bad diet and bad keeping ; in old people, it is a part of 
commencing decay signified too plainly in the loss of elasticity, and the soni- 
atrophy of the skin tissue. The neurotic aspect of the disease prurigo is well 
sliown in the burning, tingling, formicant character of the disordered senssr 
tion. The im|K>rtiuiate diaracter of the itching has been ludicrously ascribed 
to the large sixe of the |>ediculu8 ; the explanation of this theory is not given. 
Tlie burning has bci^n attributed to the ^'contact with the air of the chafed 
and excoriateil surface of the skm ; ** (But how account for this burning 
before any chafing or excoriation occurs ?) the formication, to the fact that 
the {HHiioulus m (ke Mm« tiz^ as an ant^ and ^* to the formidable-looking claws 
with which the feet of the |>ediculu8 is armed, and with whidi it clings to 
the skin *^(? clothes). The rt^asim that })ediculi occur in prurigo is this— 
\ii^ that the sute of the secretions is that exactly suited to their develop- 
ment. The cimcomitance involved in the pre«euce of pediculi in pmrigo 
does not imply cause and edfrct^ else might we ascribe the decay of orgudc 
matter solely to the influence of fungi« when the develo)iment of the latter 
takes place in c\m9e^)uence of certain antectnleut alterations in the decaying 
material by which the way for iu death and destruction is paved : the germs 



PHiniioo, S8T 

of fungi Wing ever i>resent to take edvunto^e of the opportuiiity to grow and 
help onward the process of decay. 

The foUowiug are the orguniMits against the neueBsarily pedicular origin 
of prurigo. I do not nay that pediciili may not be the exalting cause in un- 
cl«fuily fiorBons; they umy, in common with other agents, ac-t iu that way, 
but uuleBS there bo a disoi'dered 8tat« of the nervous plexne of the ttkin, and 
itn unhf^ultliy atat*- of the integument itself, no prurigo would result. Now, 
first of all, a nt-i-PRsary consequence of the pedicular hypothesis is the denial 
of thi! relation of the local fonua of prurigo — -in which no peiliculi certainly 
occur — to general pnirigo, yet iu these all the features of prurigo are present. 

The {leculiar ])ruritu8 may be present a» the prirna,ry disease, 

I haTe seen in pruidgo all the Bymptoina of dlsoi-dered sensibility in the 
eutreme, preceding the occuiTPnce of an eruption, followed by special papular 
diangea and excoriations, and no " lonse-bites " whatsoever : and in all tljose 
casea of prurigo there were signs of a decay in the akin, its vitality waa low- 
ered, it had lost its elasticity, tii-uiness, and fat, it was stained, its sebaoeouii 
secretion was disordered— the condition was favoi'able to pediculi. 

Aguin, Uiere ia no relation between the amount of em|it)on uiid the degree 
of disordered senaibiiity. The " louse-bite " can always be detected if the 
pedifulus cannot, bo that the difficulty of lietecting the presence of the latter 
it only an assumed one, 

PcdicuH placed ujion a kealtiiy surfeoe ■will not give rise to priuigo. For 
examjile, a man may sleep with a lousy budfellow, and the lice may seriously 
attack him, but be exhibita a. quantity of wltat apjieur to be Ilea or bug bites, 
with some excoriations from scratching, and he complains of itching, but he 
soon gets well, and the active repair, and the absence of the dark crusts, etc., 
are very striking. To call this prurigo iswi-ong. If a man is old, unhealthy, 
and dirty, prurigo may be evoked by peiliculi, or slighter forma of tlie dis- 
eas6 appear iu those who are out of health, as in ovei'worked students, or 
jaded medical officers of workhonses, or sickly children. But pediculi only 
act the part — beyond the infliction of the bites — of local irritanta, A pru- 
riginous condition occurs in scabies, lichen pruriginosus, strophulua prurigi- 
DOBUS, jiemphigus [UTiriginoana. In these cases we have no lice or louse-bites ; 
the pruriginoua condition is clearly due to the lowered state of nutrition. 
The last clinical fact I will mention is this : that a patient with pruiigo shall 
go to i)ed after using parasiticides, after taking his bath and putting on clean 
linen, and yet he shall have an intensihcation within a few minutes of getting 
to bed of all his pruriginoiis itching and burning. Does not this show clearly 
the nature of the disease ? 

Whenever pediculi are present in prurigo, they unquestionably play an 
aotive |iart in intensifying the disease ; tkey superadd to prurigo the sjtecial 
features of the " bites," and conduce to increase ii-ritation (and one of the 
chief points in treatment is to destroy them as early as possible), but I con- 
tend that tliey simply act as irritants and not as primary produci'rs of what 
ifcMureally a general origin, A recent writer has observed that one-sixth of 



s of diseases of the skiu in public practice are piiirigns 
origin: tliiLt they are more numeroiia thaii scabies : tbeDetwoi 
incliiding one-thitd of all outaneouB malaclion. Mr. Wilson statM, tfant of 
6,000 coDsecutive cases 'i6, or-7'2 per eeiit., weretlioae of jinirigo, 06, or 1'32, 
firuritiia, and. 148, or 3'6S, scabies. Tliis wide dUftrrence reiiuires exiiluu- 
tion. I have merely glanced over sonte of the pointa of iiitereKt, tuid t do 
protest agtdiist ihat doctrine which take« no ougtiLutDCe of Ike tfeuiirBl state 
of nutrition in {inirigo, which declares thnt loiixe-bites are chanurteribtio of 
prurigo, that general remedies are of no good, thnt tha only cure is th« iwe 
of lueroiiriai ointment to the nkin and baking the clothes, and thai one-sixth 
of t!>e pei'sonn alHictodwith skin diseaRea are lousy. 

All iiges are affected by pmrigo, but the advanced by far the moat. Prt- 
rigo is mostly seen auong tlio lowtr ordem. Neglect of ohtunliness, noitl 
depression, change of season, IhuI living, bod clothing, bud food, and aocb 
like, are peculiarly priHlisposing. Amongst oilier exuitaiita are pregnautr, 
local irriUktion, the free use of Btiimulaut«, and untiasstdouably tlie preacnce 
of jiediculL 

JKatpioais, — Prurigo is known by the peculiar dark osjiect of the ['■ pu ttr 
at their apices, their dissemination on the ontcr and posterior aspects ^tbi 
limbs and back ; by the peculiar firurituB, the iiuliealtliy, flaccid, dir^ aMa 
of skin, and the uniformity of the entption. In lichen, the papuln> ore ligh^ 
colort^d, and without dark apices; the diwase occurs on the inner as[M)ct tiT 
the limbs, etc.; there is no " orticatiou," the siir&ce is not withered, but 
dry, thickened, harsh, not llaccid. In scabies, (he eru|)lion is niultifonn, 
seated nhont the iiiterdigital sjiaceK, on the front parts of the anns »nd bodj; 
the aldn is apparently healthy, there is no burning pruritua ; it also oooursoa 
the Huats of pressurn, es]>ecially the tuberosities of the iacliiam, anil axhihita 
the characteristic veaiole and furrow; in addition pi-urigo occurs not onir 
on the outer aspect of the limbs, but altto gi'iierally above the level of th« 
nipple-line and below the upper jHirt of the thigh ; scabies, on tha other baad, 
is seen mostly between these two liues of domarcation. hi yrmgn, pedt 
culi are detected. 

Scabies and pnirigo may be conjoined. Here the characters of the tm 
diseases coexist. 

Trtatmenl. — 8[>e«king generally there are tlireemun objects: the first to 
improve the tone of tlie general health ; the second to allay the initKtinn 
of the skin, when tlio secondary chains of papulation and the like snbnda; 
and the third to destroy any pediculi that may be present ; and llua \mltX» 
point must always be attended to. Pudicuii «■« readily destroyed by diuig- 
ing the clothes, which should be baked or thoroughly scalded, by caroAil 
tepid bathing night and moi-ning, and the use of ammonio-ohlorido of jomen- 
ry ointment, stavesacre ointment, or a solution of the pyrethrum roMun, 
and the removal of flannel from next the skin. I never find any diffiooltjr 
in getting rid of them. If I am very maiiduoua in their destruction, I di- 
rect a powder in small amount composed of equal parts of oxide of xinc 



indovpr the clothes 
nain reasou of fail- 
the pit-Btriiition of 
I be resoi-ted to un- 
of pni- 



PRT'KinO. 

nd white precipitate to be sprinkled about the armpits 
■which come in cont-act with these parts. I believe the 
nre is ioattention t^i change of clothes, and neglect in 
proper ablution. The destiiiction of pediculi then is V 
tier all oinsiimstanceB. Now, -clinically regarded, the 

rigo tJittt occur may be Ciii-ly nrninged iutofivo groups. (1) Canes in which 
prurigo nf a mild form complicatea other diaeaaea, frequently in young peo- 
ple, as in Unhen pruriginosui;, again t» peniphiguB prurigiuosns, and even 
scabies. In these cases all that ia needed is tlie exiiibition of cod-liver oil 
and <)uinijio with better food. The pruriginous element is an evidence of 
special mal-nutrition of nei^e origin, in which probably unoleanliness, in 
addition to bad living and feeding, bos had much influence. A better hy- 
giene and tonics, with perhaps alkaline baths, never fail to effect the deured 
duingir. In the case of pruriginous scabies, the cure of the itch in the first 
Btep ; and tonim are specially useful according to my experience. (2) The 
Beoond class comprises cases in which prurigo oconrs in middle-aged men 
ttnd women, in whom the pruritus is not of so decidedly a burning, formi- 
cant, character as in older folk : the skin is often tolerably well nourished : 
the atrciphous state is but slightly markeil. Here we get pediculi, and in 
snoh cases the maiu cause of their presence and their activity is to be found 
in tolerably bad living, a scanty change of linen, and absence of cleanliness. 
In tliese cases the cure is easy, by the 'destruction of the pediculi, together 
with enfoi-ced cleanliness. (3) The thii'd batch of cases is that in which 
old people are attacked, and pediculi are present. Here the utmphous 
state of iiit«gumont is more marked, aiid independently of the destruction 
of any pediculi, much requires to be done to improve the niitiition of the 
ridn by general remeilies. Arsenic is here admissible. The skin, too, is in 
these cases oftentimes very irritable, and, as a oon!iei:|uence, the pruritus is 
intense, and aggravated by change of temperature, by hot drinks, etc. It 
may bo relieved by tepid and alkaline bathing. I do not comnieud the plan 
«f applying tar, sulphur baths, and the like, to caaes of prurigo such as 
these. There can but be the frequent result of over-atimulatiou. Inter- 
nally, the mineral acids with strychnine, or in severe cases aconite, are the 
beat remedies ; whera a gouty tendency exists, the iodide of potassium is of 
use. The action of the kidneys also needs to be encouraged, by diuretics, 
in some of these cases, Tlie circulation of bile products, aud their non-ex- 
cretion. ai« a^ravating influencea in other instances. The local irritation 
must be allayed by the adoption of scrujiulous cleanliness, and by the appli- 
cation of vaiioua emollients and sedatives, which are found useful in the 
other varieties. The moat common ia one composed of from two to three or 
four grains of the bichloride of mercui-y, with two drachma of dilute hy- 
.diocyanic acid, and eight or ten ounces of water; lotions into whose com- 
I watery extract of opium, bellajloniia, and chloroform cuter are of 
« ; several of these will bo found amongst the formula: ; a good lotion 
Ji cyanide of potassium. For geuei-al use, the following may be 



240 NEITROBBS OF THE BKIN. 

euipioj'ed : liquor plunibi two diucbms, biborate of soda a dracbui, j(l;cenw 
two draclims, oud litne'Water six ounces. When the pruritus i« Hirera ife 
cestiatioii or dimiuution ifl ratber to be exjiected from sedatives given isll* 
nally tbau lotiaiia and jioniiides extenuiUj. 

Now in some of these caaeH ecbliymutoua pustules appear. This is to a 
an iniUcation for the exhibitiou of ccxl-liver oil or quinine. In certain catt 
where the disease depended rather upon an atrophy than the iuiIueD08 ( 
-pedicuU, I liave found the little fat glands plugged up with cxuvtar, ax 
have beeu startled, on examining thejae witli the uiicroscojte, tu notice tlie 
large number of fungus spores therein, I have seen good results in suck 
cases from the use of hyposulphite of soda lotion (half an ounce tu half a 
pint of water). (4) In the fouith gi'oup of cases the most Irottblesotne 
instaucca of the disease are met with — those in which the pruritus is moM 
inteiise, and out of all proportion to the "eruptive" uiauifestations ; tlu 
prurigo is here sometimes clearly a part of a general distnrbaaca of the 
8yst«m in which the nerves play the prominent part. For examjde, in ooo- 
nectiou with asthma or long-continued and severe " pyrotlc " syioptoiDS, or 
it may be a gouty tendency. The atrophy of the skin may be very wdl 
marked. These ai^ the most diffi.cult cases to treat, and those which piizsle 
the pi-actiliunor. Attention to diet, which should be unstimulating. regul^ 
tion of the eecretiona, the use of opiates in connection with tonics, snob ms 
ammonia and bark, strychnine, nitric acid and quinine, as the case rasy be, 
or tinctui*e of aconite in moderate doses, with digiljtlis, wliere this is admi*- 
sible, are the remedies of best action. Locally, lotions of various kincle 
may be employed ; and here it seems Umt we must act empirically ; iu aotne 
cases dilute uitiic acid lotion ( 5 j- — 3 iss. to § vj. of water), m othor times 
alkaline lotions— ex., carbonate of soda ( 3 ij- ad ; vj.], prussicacid, ttibaeeo, 
the hot^iir bath, etc., are serviceable. I frequently use the following: — 
Tincture of uux vomica, two draduns ; tincture of digitalis, two or thr^ 
dnushms ; glycerine, two drachma ; and water, to six or eight ounces, ITds 
Bsnie kind of non-pedicular prurigo is seen occasionally in middle-aged sub- 
jects ; then it b pretty wtll distiihuteil over the body, but esi>ecuOly uffteta 
the shonlilei's, arms, neck, lielly, legs, and about the calves. I havu known 
it associated with " drinking habits." Free excoriations are caused by the 
scratching. 

Hero 1 have found that treatment has been successful in proportion to 
the degri^e of personal control I could exercise over my patients. I do not 
hesitate to purge, to give diuretics fi-eely : to moderate the " heat of tbe 
body," dwilared to be present, by digitalis, and even atitimouials. Colehi- 
cum may be also needed, reserving the mineral acids and bitters til! » Uur 
stage. Locally, the attempt should be made to exclude the air by &ee 
smearing, lii'st of all with a glycvnne and zinc or leml plasma, and then 
" wiiitewashing " with oxide of xiiic and wat«r, or a whiteniug-paiit^, or even 
painting with glue and whitening. Saturation at night in a strong »llf H"» 
bath la another good plan. Alcoholics ai-e to be avoided, togelhQ^dtf^J 






PBUBIGO. 



241 



^^ 






*■ i * 









■ 
I 

T 



seasoned dishes, pickles, spice, pastry, salt meat. (5) Lastly, the local 
TBiieties need to be noticed. In prurigo of the anus ; haemorrhoids, iilcers, 
and ascarides of the rectum are at the bottom of many cases ; the two former 
require surgical treatment. In other instances there is an eczematous state 
present, which is removed by zinc and lead lotions. In other instances the 
affection is purely neurotic : here, keeping the bowels relaxed, warm water 
injections, poppy-head fomentations, belladonna, opiate lotions, and black 
wash, constitute the agents of relief. In the other local varieties similai 
means are to be used ; but there is one exceptional condition — viz., pnirigc 
pudendalis ; when the vaginal mucous membrane is inflamed and irritable, 
a borax lotion, or one composed of hyposulphite of soda, does much good. 

The observance of a rigorous personal hygiene is one of the most im|K)r- 
taut points in the therapeute of prurigo : this, with good unstimulating diet, 
alkaline baths, astringent and sedative lotions, after destruction of pediculi, 
with opiates internally, constitute the basis of treatment. But I must add 
finally that in some instances, where debility is extreme, a free stimulating 
plan is advisable. See Formulw Nos. 29, 36-7-8-9, 41, 45, 47-8-9, 50-1- 
2-^-4, 61, 66, 69, 105-6-8-9, 122, 141, 146, 151. 



CHAPTER XX. 



HiEMORRHAOES. 



I AM indebted to my friend Dr. Buzzard for the following note on Pur- 
pura, the only disease which I have to describe under the head of h»mor> 
rliages. 

The skin is liable to be discolored by hcemarrhagea into its structure. In 
typhus^ petecliisB or spots of h»morrhage are very frequently observed, and 
in other acute specific disorders purple discoloration from h»morrfaage 
may accompany, or even replace, the natural eruption, in cases of ez* 
treme virulence. This is every now and then observed iu variola^ 
scarlatina, and rubeola ; also in the course of chronic disorders, as of the 
liver, spleen, and kidneys, purple spots may appear on various parts 
of the skin. The term purpura is often applied to these conditions, and 
some little confusion has thence arisen, because by the same name is also 
designated a disorder which \& independent apparently of specific poison, or 
of chronic organic disease. This disease may be very mild or (rarely) Teij 
severe. In the former case it is called purpv/ra simpleXy in the latter pur- 
pura ham%orrhaglca. It is characterized by cutaneous h»morrhage, giving 
rise to spots, patches, or bruise-like discolorations of the skin ; and in the 
severe form the hsemorrhage also comes from any or all of the mucous sur- 
faces. 

'^ Purpura \& most commonly seen in its early stage as a minutely fine 
ei-uption of pin-)>oint-8ized specks, of a pink or puq>lish color, covering the 
skin more or less extensively. The eruption is especially apt to appear on 
the lower extremities, and it is usually most marked about the thighs and 
buttocks. In these situations there is usually a rapid aggregation of the 
specks into patches of iiTegular shape and size. After a few days there are 
intermingled with these, yellowish or buff-colored patches, which are the 
sequeke of the earlier eruptions. Here and there, too, will be seen bruise- 
like discolorations, extending over a larger surface. 

**The same words will describe also another disorder — scorbutus — which, 
however, can be readily distinguished from pui*pura, by the following char- 
acteristics : — 1. It is always caused by privation of fresh vegetable food. 
2. The gums are usually swollen, spongy, discolored, and bleeding. 3. 
There is always great lethargy and prostration, and the skin is of a pecu- 
liar dusky, dirty-looking pallor. These features are not observed in pur- 
pura. A purple eruption, then, which is not coimected with the exanthemata^ 
nor with chronic organic disease, and the history of which does not cor- 
respond with the characters of scurvy just given, may be safely set down as 



H.£M0RRHAaE8. 243 

purpura. Another point of diagnosis still remains. In all forms of cutane- 
ous hfemorrhage there is a gradual change of color. First a more or less 
bright pink spot appears, which becomes in succession purple, brown, tawny, 
buff, and yellow. It never fades on pressure. Under these circumstances 
the spot at one time may look a good deal like a flea-bite, but it will be 
found to have no central puncture. The spots may be single, or aggregated 
into patches. They tend to appear fresh every day, or at short intervals. 
Under the use of fresh vegetable food the appearance of new spots is im- 
mediately checked, if the case be one of scurvy y but i£ purpura be the cause, 
this diet will quite fail to influence the progress of the eruption. 

'^ As regards treat7nefUy the cause must first be ascertained. Nothing need 
here be said respecting the management of cutaneous haemorrhage occurring 
in the exanthemata, or in chronic organic disorder. If scurvy be the cause, 
the patient must be immediately furnished with fresh vegetable food, and 
good generous living. Lemon or orange juice, potatoes, cabbages, and let- 
tuces are of es}>ecial value. The skin should be kept clean. The patient 
should be kept for the first few days in the recumbent position. No drugs 
need be given to him. The etiology o£ purpura [)roper is still but ill under- 
stood, and any treatment for it is therefore necessarily empirical. Tur|)en- 
tine, the perchloride of iron, and quinine have apparently produced the best 
results.'' See Formula 135. 

I may just add that purpura is sometimes complicated urticaria, and then 
we have what has been called Purpura urticans. I have also seen purpinti 
take its origin in abortive zoster. The attempt at the formation of bull» 
ISuled, and in the place of these formations purpurous spots appeared. 
16 



CHAPTER XXI. 

CHROMATOGENOUS DISEASES — PIGMENTARY. 

Alterations of color are produced of course by many different conditions — 
by an alteration of the blood current, by parasites, and other agents. These 
have been classified, in speaking of macul», under the head of elementary* 
lesions. Reference is now made to cases in which the pigment-sup] ilj of the 
skin is alone concerned. Now, there are two groups of cases : — (1) Those in 
which the pigment is deficient in quantity (Leucorderma)^ and (2) those in 
which it is in excess {Melunodernui), These may be congenital or acquired, 
general or local. The seat of change is the rete mucosum. 
First with regard to 

LEUCODERMA. 

Tliis may be general or partial. The former condition is represented by 
the albino, whose whiteness is congenital. The physician lias to deal medi- 
cally with the partial variety. Now, there are two conditions producing a 
])ai-tial wliiteness — the one in which the pigment is deficient in one spot, but 
perhaps in excess at the adjoining part; it is not equally distributed ; there 
may be no excess on the whole, nor deficiency, but unequal scattering. In 
the other case the geuei*al surface of the skin is normally colored, but there 
is an absence in some one or more parts locally. The former condition I 
have S(H3n in young men who have been exposed to the s\m in hot climates, 
have had fever, and then returned to England ; it is not very common. The 
latter variety — that is, true partial leucoderma — occurs especially in the 
black races, and consists of circular white patches giving a piebald appear- 
ance. In leucodermic patches the hairs ai*e often white. The only change 
in the derma is tliat of pigmentation. Eveiythiug else is normal, save per- 
haps the sensation, which may be blunted. The extent of the patches, which 
may be round or serpentine, or in the form of bands, varies. The disease 
may cover the chest and back, white and dark blotches being intermingled ; 
it occurs in youngish folk. I cannot but think exposure to the sun's ravs 
has much to do with its production, deranging the pigment-formation in the 
skin. 

IJinfjnosiii, — The fact that there is simply deficiency of the pigment with- 
out other change, save an a])parent accumulation in |)arts of the skin conti- 
guous to the white patches, must be diagnostic. 

Pathology. — It seems clear that the distjase may arise from depressed in- 
nervation ; the action of the sun oftentimes sufficing to determine the 
occuri-ence of the disorder. 



HELAKODKBMA. 245 

TVecUmerU is often successful. A nutritious diet, a course of tonics, arsenic, 
iron, and the mineral acids, the correcting of any of the ill effects of the 
action of malarial poison, residence in a cool locality, and avoidance of 
fatigue, generally suffice for improvement. Locally, the use of friction and 
cold bathing, with iodine baths,, are the best remedies. 

MELANODERMA. 

This term of course means excess of pigment resulting in dark discolor- 
ation, but the altered tint of skin may be blue, yellowish, or black, hence the 
terms cyanoderma, xanthodeima, and melanoderma. A short descnption will 
suffice for these. 

3fdanod€rmaj or that in which the discoloration is black in color, is 
general or partial. The latter is sometimes called melasma. There is a 
general dark discoloration associated with disease of the supra-renal ca])sules, 
and now known as Addison's disease. I need not desciibe this. Tlie local 
variety, or melasma, is important. It may be a '* physiological " condition, 
as seen in the staining aroimd the nipple and the linea alba in pregnancy ; 
this condition may be excessive. Dr. Swayne has described a case in which 
there was a peculiar discoloration about the face, arms, hands, and legs, 
which were spotted like a leopard. The same woman thus affected exhibited 
like phenomena in her skin during the last three months of her two former 
pregnancies, the discoloration disap|)earing after each confinement. Then in 
anaemia, discoloration of the skin may occur about diffei-ent parts of the 
body. In connection with the syphilitic diathesis the earthy and very 
characteristic aspect of the surface, especially the face, is a melasma. 

Xjentigo is a variety — it is known as freckles. The seat of the pig- , 
mcnt deposit is the rete mucosum ; it is often congenital, and of varying 
extent and distribution ; generally, however, consisting of round yellowish 
spots, the size of split peas and less, not only on the parts exposed to the 
light, but also that covered by the dress, in those with fair skins, and par- 
ticularly red-haired folk. Tliere is no desquamation, no itching, and no 
heat of any kind : freckles often disappear after puberty ; do not depend upon 
seasonal change ; and require no treatment, except slight stimulation, ace- 
tate of lead, sulphate of zinc, and iodine lotions. 

JSphdis (or Sunburn), — In this particular variety of discoloitition the 
pigment deposit is excited by the sun's ra3's. Sunburn consists of little dots 
the size of pins'-heads, which appear upon the parts of the body exposed to 
the influence of the sun, and are seen mostly in lymphatic subjects with 
delicate skins. Treatment is of little avail. We may, if we choose, use a 
little bichloride of mercury lotion. 

Melasmic discoloration of the skin occurs in certain states of the blood — 
6.^., anssmia, syphilitic cachexia — as the result of the action of local irri- 
tants, such as the s\in, strong light, blisters. It also follows chronic erui)- 
tions — syphilitic roseola giving rise to syphilitic maculse. Indeed all fonns 
of syphilitic disease leave a pigmentary staining behind, of course in this 



.246 OHBOltATOOBNODB DISEASES. ■ 

gioup of eases the melasma b a secondary and not a primary form of di^eiae. | 
Another melasma is foHiid in pigmentary luevi, which are round, small, fed 
smooth to the touch, covei-eJ with a number of soft haira aud pigmetrtod 
brown or black. These moles occur on the body, but espetrially th« face ud 
back ; they are slightly elevated, ara not nevoid in struetiire, and aiuliei;ga 
little change ; they are merely cullections of pigment in tbe ret« uucoaoa; 
they may cover over a large extent of surface, from several inchea to a foot 

JCtait/toflentut.—lii this diaea^^ the pigiuentaty discoloration is ydlowiiK 
It is characteristic of certain races, and ia due to some special couditlou of 
the coloring matter of the skin, molecular or chemical. 

Cyeinod^rma, or hlue discoloration, is dilfereut firom colored swekt. It la 
a curiosity, if uot, at least in the greater uumbt;!' of instances, a koox. A 
ouriottfl disease ia described by T>r. Arcken as endemic iu New Graunda and 
the noi-lliem parts of America, and is called Carate: it ia diathetic, and 
charact«rized by the appearance of various colors on the body — dull whit«, 
cop|ier, crimson, red, and dark blue- — so it is said. There appear to be three 
varieties — the simplest, Uue, whiuh is seen between 15 and 25, aud oonusta 
of oval or roundish spots on the fa^e, extending to the neck and lower limba 
even } the vjhite, occurring between the ages of 30 and 40, rare in "'a-tf , 
and usually associated with ovarian disease : this is leucoderma : lastly, the 
ro»»-eoloreJ, cousistiug of red points on the hands, face, and belly, soea in 
both sexes. It is said to be due to bad living. 

PttOitAogy. — Mr. Wilson thinks that there is an anemia of special 
featui'es, accompanied by pigment deposit aud change, due to ilebility of the 
nervous powers, and that the various colors are modified results. Especially 
ia reference to melanoderma, he uocices a peculiar condition of eye — " tbe 
meiaamic eye." It consists of " a vivid brightness and brilliancy and spaur- 
kliuglustre of the eyeball, a liquid depth of color of the humors of the eje, 
and a strongly contrasting whiteness of the sclerotica, the effect being often 
increased by a more or less deep tint of a dull blackness of the iuteguiuenls 
of the eyelids, more especially of the fold of skin of the upper eyelid wlueh 
immediately borders on the eyeJushes." The non-produotion of pigmeat 
may arise from local destruction of rete mucosum, etc. ; from want of nutri- 
tive power, as in leucocythwmia ; and, on the other hand, an excessive pro- 
duction is brought about by imperfect oxidation — the carbon is not burnt off 
as carbonic acid ; by the imperfect eliviin/ttioH of the carbon, in deficdent 
menstruation, diseases of liver end kidneys, deficient hair-formation, durii^ 
disease in pregnancy (leucocytosis present), and by l!i« excetrive prvhiction, 
from the use of highly carbonized foods. Such are the causes given by Dr. 
Laycook. The above remarks apply to cases of tnie piguient-alteiKtiou. 
There is great distinction to be drawn between these mid states of abuonual 
coloration, due to an alteration of the haiTuation of the blood, and not to the 
o production of pigment, as in sallowness, icterus, chlorosis, Morbu- 



md splei 



: disease. 



CYANODERMA. 247 

The Dioffnosis of these discolorations offers no difficulty ; the color is 
altered, and that alone. 

TVecUment, — This is generally that of an»mia. Locally little can be done. 
Organic disease must have its appropriate treatment. Sometimes there is 
excessive waste going on in the system ; in that case the diet, the use of 
stimulants, nerve tonics, change of air, mental rest, and the diminution of 
anxiety, are the points which we should look for preventing depression of 
the nervous innervation and for toning up the powers. In this way both 
imperfect oxidation and deficient elimination are met. One other important 
thing to do is to see that the amount of red corpuscles in the blood is suf- 
ficient. I think that the deficiency of the red cells may be one factor in the 
causation of melasmic stains, and for that reason I use iron as a remedy 
against them. Then I am inclined to think that the action of the malarial 
poison on the system may tend to an abnormal production of pigment in 
the blood, so that in pallid neuralgic subjects large doses of quinine are 
called for. Though I do not think local remedies of any direct use, yet free 
ablutions, and frictions with the use of juniper tar soap as a stimulant, help 
the skin to recover its healthy condition. 



CHAPTER XXII. 

DISORDERS OF THE OLANDS. 

We have two sets of organs to deal with : the sweat or sudoriparous, and 
the fat or sebaceous glands. I think bot!ii these parts of the skin are much 
more frequently disordered than is generally supposed. I shall first spetk 
of— 

I. diseases of the sweat glands. 

The deviations from health may be functional or structural ; the former 
include all those cases in which the sweat varies in amount and kind ; the- 
latter those in which the sweat follicles are likewise congested, obliterated, 
inflamed, or enlarged. 

The disorders may be arranged thus : — 

A. Disorder of Function, including hyperidrosis (excessive sweating), 
anulrosis (diminished perspiration), osmidrona (change in odor), and chro- 
midrosia (change in color). 

B. Structural Disorder : miliaria and audavihia (congestive dis- 
ordei's), lichen tropicus (folliculitis), airophulvs (inflammatory), hydnh 
adenitis (suppurative), and cysts^ due to follicular obstruction. 

First, then, A — Functional Diseases of the Sweat Glands : — 

HYPERIDROSIS. 

This disease is excessive sweating. It is, however, not generally an mde- 
pendent form of disease ; it is often the case that the circulation tlirough 
the glands becomes disordered, and hence we have structural changes, con- 
gestiou and prominence and effusion into the follicles, constituting miliaria 
and sudamina, and other diseases, to be desciibed in a moment under the head 
of sti-uctural changes. Tlie mere excessive sweating is a functional disorder 
of coui-se ; it may be partial and chronic. It generally depends upon some 
loss of control by the nerves of the part. In excessive sweating (hyperi- 
drosis) the sweat is acid and somewhat disagreeable. There is generally a 
feeling of chilliness, and locaUy in the skin, pricking or burning. It may 
be " critical." The local forms occur about the hands, feet, and neck, and 
scalp. In hot weather, about the hands and feet the sweat (being free all 
over the body) may not be able to escape readily in consequence of the cuti- 
cle being roughened and hard ; under these circumstances it distends the 
bwcut-follicles, which may be seen dilated and filled with fluid beneath a 
layer of cuticle. This is often mistaken for eczema ; one or more patches, 
tlie size of about a shilling, suiTounded by redness, are seen at the sole or 



side of tlie foot, ubout Llie Heshy jiurt of titc tkunib or the pulm uf tlie 
liuid. Oa viewing them witli ft glosB, there is what apfieiira to be vesieulu- 
tiun tmdei' the ekin, whilst each patt^'h is raised ; but there ai'e iio vcaicular 
piiHuiaences, in fact the glands are (sub-epidermiciiily, so to sjieak) dis- 
tended with fluid, aa I have said, which caimot escape. The sensaliou of 
bumiiig aiid pricking is marked : after awhile the cuticle bursts and the 
fiuid is diHchat'ged, leaving behind a hot, red, [>eeling surface, which by fits 
imd starts weeps, the escaping fluid evidently being sweat; or if there is no 
escape of fluid, tlie attacked parts swell, they become red and shining, and 
are exceedingly [)aiuftd. Ther<! is uo formation of crusts as in eczema ; the 
cuticle peels oiT, and presently the redness aubsides. This is not eczema; 
it is simply hyperidrosis, with difficulty of escape of perspiration. The fol- 
licles are not congested and inflamed sensibly as in miliaria. The treatment 
Oonuists iji cai'eful bsjidaging, the application of lead lotion, the sedulous 
exclusion of the aflected surface from the air, and the use of diuretics. lu 
Home cases the use of an oxide of zinc lotion, with an aperient, will suffice. 
Hyjieridrosis may be an acute disease of Budden occurrence, when it is gen- 
eral ; or it may be local and chronic. 

ANIDROBI8. 

This disease is characteiixed by a diminution of perspiration. A dry 
ekin is part of many general diseases — ex., fevers, diabetes; in xeroderma, 
in which there is congenital defect of development. More commonly, it 
arises from allowed inaction of the cutaneous covering ; and the use of fric- 
tion, warm bathing, alkaline batlis, and the like, generally bring the skin 
into a proper state of action. There is of coui'se in these eases more or less 
general debility, which muHt be specialty Attended to in each instance. 

OSMIDROSIS. 

This is that disease in which the odor of the perspiration becomes so 
offensive as to constitute " the thing to be remedied." 

It nwy coexist with other functional derangements of the sweat appara- 
tus. In general diseases the sweat exhibits very peculiar odors; in i-beu- 
ma^m it is " rank," scurvy " putrid," chronic i>entonitis " musky," itch 
"mouldy," syphilis "sweet," jaundice "omsky," scro^la like"Kt»le beer," 
in intermittent fevers like " fresh-baked brown bread," in fevers " ammoni- 
«eal,*' and so on. When the feet are aff&cted, the sweat is sometimes most 
oflensive, especially in the summer-time. Hebra describes the condition 
very fully. The hands and feet of the afflicted are cold without their know- 
ing it ; they exliibit sliining drops of sweat ; the epidernus is macerated and 
presents a white wrinkled ap]>earanco ; excoriation may result, and with 
these conditions the ofiensive odor exists, Hebra believes that the .smell 
is not inherent to the sweat, but (external) in the boots and socks, ^^ffl - 
is, no doubt, true to some extent, but it would seem also that ^^ji^&iiiiv. 
gnskiest cleanliness is observed, some people's feet axs most unfortuuaCelA- 



250 DI80BDEB8 OF THE GLANDS. 

net of the sweetest smell. There is often a blueness due to inactive circii- 
lation in the tissues. The treatment is a matter sometimes of great tediooB^ 
ness. Much may be done by rigid cleanliness. If the disease be due to 
saturation of long- worn socks and boots, with acid sweat which decomposes 
in them, then the removal of the cause of offence is easy. lu ordinary cases 
the feet should be well washed and bathed in a solution of alum or Condy^s 
fluid. The use of a light sock and shoe, lotions of creasote, or finally strap- 
ping each foot for twelve hours together, as suggested by Hebra and Martin, 
with diachylon plaster, are useful. (Some observations on foetid perspira- 
tion will be found by Dr. Foote, in the Dtiblin Quarterly Jhwrrud^ for May, 
1866). 

CHBOMIDROSIS. 

Black, blue, and sanguineous perspiration are included under this term. 
Much has lately been wiitten on the subject. Chromidrosis is often con- 
nected with menstrual disorder, and is due to the escape of the coloring 
matter of the blood, or actual blood, with the sweat. It is an unimportant 
disease. 

B. STRUCTURAL DISEASES OF THE SWEAT GLANDS. 

Under this head I have included miliaria and sudamina (for in these the 
vascular plexuses of the follicles are specially involved) ; lichen tropicus 
and strophulus, and hydro-adenitis, or suppurative inflammation of the fol- 
licules. 

MILIARIA AND SUDAMINA. 

These two aflections really have no right to be considered as separate 
diseases. Sudamina is the lesser degree of disease, the contents of the 
vesicles being acid ; miliaria is the more developed condition, in which the 
contents are alkaline — in fact, inflamed sudamina, as Dr. Gull pointed out. 
Sudamina have been described as little round vesicles, produced by disten- 
tion of the cutis by sweat, and therefore seated at the orifices of the sweat 
follicles. This is an excess of the condition referred to under hyperidrosis, 
only that these are distinct elevated vesicles, which are never confluent, 
and unattended by any inflammation : when the latter is present, the aflfeo- 
tion is called miliaria. Sometimes the vesicles are reddish (miliaria rubra), 
sometimes white (miliaria alba). These vesicles are developed about the 
neck, axill», clavicles, and trunk, in diseases in which profuse sweating 
occurs ; their contents quickly dry, each crop is replaced generally in from 
three to six days by furfuraceous desquamation. The disease is seen in 
phthisis during summer-time, in acute febrile disease, the parturient state, 
in rheumatism, fevers, in the sweating disease of Picardy. Since the adop> 
tion of a cooler regimen in sick-rooms, the disease has been altogether less 
frequent than formerly. So-called miliary fever (said to occur in two forms, 



STKOPHULUS AND LICHEN TROPICUS. 251 

mild and malignant), is characteiized by profuse sweating and the develop- 
ment of sudamina. The ti*eatment demanded is a cool regimen. 

STROPHULUS AND LICHEN TROPICUS. 

I have already referred to these two affections, under the head of lichen, 
to which disease I refer for a description of their characters. I believe 
that they should be transferred from their present position, and placed 
under the head of disorders of the perspiratory glands. 

The part of the glands affected in the above diseases is the follicular. 
We now come to a disease in which the whole gland is involved. 

HYDRO-ADENITIS. 

Yemeuil described this disease, which is an inflammatory state of the 
perspiratory follicles, ending in suppuration. The disease occurs in every 
region of the body where there are glands, except in the sole of the foot ; 
but it is most frequent in the axilla, at the margin of the anus, and near 
the nipple. It also is seen on tlie face, about the ear. The disease com- 
mences by a ci*op of small inflammatory tumors, about the size of peas, of 
bright-red hue, and (says M. Vemeuil) at first like boils ; they are unlike 
boils in the fact that the little inflamed indurations begiiL not on the sur- 
face of the skin, in a sebaceous or hair follicle, but beneath the skin, which 
is reached and involved secondarily. The suppurating follicles offer no 
prominent "point'' or "head,'' and there is no discharge till the swelling 
bursts, when the disease is brought to a sudden termination. The causes 
are said to be uncleanliness, friction, the contact of irritants, pus, parasites, 
profuse perspiration, and, according to Bazin, the arthritic dyscrasia, sy- 
philis, and scrofula. The disease is often mistaken for scrofuloderma. The 
treatment consists in the use of alkalies internally, hot fomentations, and 
soothing applications — lead lotion and the like — externally. I find collo- 
dion the best thing. 

The above account is taken from an article in the Journal of Medicine 
and Surgery for October, 1866. I have had several cases of this disease 
under my care. The last was that of a young woman, who had two or 
three red, subcutaneous " lumps " under her eye of bright red color, and 
the size of peas, with no central suppuration. In a couple of weeks the 
tumors " broke," and the face rapidly got well. 

OBSTRUCTED SWEAT GLANDS. 

In some cases one sees developed in the skin a cyst, which takes its 
origin in a dilated follicle or sac of the perspirating gland. The follicle of 
the latter becomes obstructed, and instead of the gland inflaming and sup- 
purating, the fluid collects and distends the follicle. The line of demarca- 
tion between hydro-adenitis and cyst formation in the early stage is not 
well-defined. I have seen " serous " cysts of this kind form on the face 
from the closure of the perspiratory ducts, by the cicatrices of acne in a 



252 DISORDERS OF THE GLANDS. 

strumous subject, and most difficult the disease was to cure. I found ^^ 
continuous application of collodion the best treatment ; the cysts, howe'^^'er, 
may be punctured, and the contents allowed to escape ; the incisions qb. ^aist 
be deep enough. I now come to 

11. DISEASES OF THE SEBIPAROUS OR SEBACEOUS OLAXD8. 

As in the case of the sweat glands, we may divide the diseases of "C^e 
fat glands into two groups. 

a. FrxiTioxAL — uicluding stearrhoaa or sehorrhcea (increased secretions), 
asteatoiies (ileticieiLt secretion), and allosteatodeSy or alteration in the ch; 
acter of the secretion. Retention of secretion is usually accomiiauied 
alteration of structure, and I shall desciibe it under the latter head. 

h. Strivtural. — Diseases of the lining membrane — ex., pityriasis, vitLXi 
goidea: retention of secretion and its consequence — ex., comedo, sebaceo 
cysts, molluscum : and lastly, congestive diseases and inflammatory 
— acne, furunoulus, etc. 

We notice first of all, then, 

A. FrNCTIOKAL DISORDERS — SEBORRHCEA. 

S^borrhaa^ or auifmentAi sfcrftion of Jattf/ matter^ fdme^QHS jlux — 1]» 
stearrhu'a of Wilson — is not so verv imoommon in the various diseases o 
the surface : in elephantiasis it is a marked feature. Some persobs hav 
naturally a greasy skin. 

When oocurring as a se|4urate ilisease, it<> most usual seat is some part <^ 
the fact\ es|Hvially the nose, and it mostly shows itaelf in the form of littl^^ 
yellowish thin crusts, which on examination are found to be made up a 
»el>a«xvus and epithelial matter, the epithelial cells of the sebum being loaded 
with fat iutermiiurkHl with tree granules and cholesterine ; the skin beneatb 
is nxldeiuHl, uioiv or less thiokeneil, and the ^baceous glands arv hypertro- 
phie\i. It may give rise on the scilp to a kind of pityriasis; the scalp iiow'* 
over is croas v, not drv. There ma v be itohiui; — cenerallv there is. It often 
disapi^^rs at'^er a time. Tlie causes ane not well made out ; it is said to be 
pnviuvwl by over-siimulatuig vliet in lymj^iatic subjects; it occurs in either 
«ex, cenerallv alxnit pulvrtv. The treatment consists in the exhibitioii rf 
coil'liver oil and ani«.nuo, the rtnuo>'al of the scales by alkaline lotions, and 
the Kval use of a!u:u, lnoh;ori*ie of mercurv ointment, and dvoeval tannin. 
Now the stvrt^tioi; m.-iy viiry i:; vvusister.ce aud quality in ^K>rrboBa ; it may 
Iv oily, iiud tht'n rt^.^r^^i^^uts :ho *<*riO a*1^*.\v duer.:e : when it forms crusts, 
the aone sel\*^"yv vviion. :<.v : aiid. i:i a uK^re harvieaed state, tlie acne sebaofe 
comee of the Kr^nu-h wrii^rs^ Thi^i^* terms sv.£cieQtly explain the diflerant 
apiHtftnu.oes of the d:A^iiA\ Ir. savAj^ir^ of ioLthjvwi* it will be tv 
that I staxevi that the s^'ali'.'.t^jss or hv^niy pi*:*'* were \>ftea made up of a 
aiuvnr.;: of fcitty luAtter : the d:ii«c^<^« I sow 5%«eak v>f vvvurs as a priiiiy eoB- 
dition; in iohthvvxsi* i: is W.: y^rt of a fiecrrral disoritr <4 the akin. Blitn 
civtft? iv:ftrniKanvv to iohth^vxus tuay W ^>i\xhuwi by ttrK^nhana; the 




STRUCTURAL DISEASES. 253 

eye appearances of the skin may be the same, only the disease is localized, 
the skin beneath being naturally healthy. 

ASTEATOliES 

Is deficiency in the eehaceovs secretion. The skin appears to be dry and harsh, 
and this arises from deficient action of the sebaceous glands. Asteatodes is 
seen in hereditary syphilis, and in badly-nourished or uncleanly folk. The 
tnreatment consists especially in the use of the bath, oily infrictions, generous 
diet, and tonic remedies, especially cod-liver oil. 

ALLOSTEATODES. 

AltercUion of secretion is the characteristic of this form of disease. The 
secretion may be of various colors — yellow (seborrhoea flavescens), or black 
<8<Mialled setorrhoea nigricans). 

Seborrhosa flavescens is nothing more than a marked form of S. simplex ; 
Indeed is the same as the acn6 sebac6e concrlt^, only that the color of the 
scaliness is yellowish. The sebaceous matter is thick, yellow, forming scales ; 
the disease aflects the nose, limbs, or trunk : there first exudes an oily trans- 
parent fluid, and this quickly conci*etes. The crusts may become hard and 
adherent (A. S. com^). Sometimes the sebaceous matter is black : this is 
the stearrhoea nigricans of Wilson. The color is produced by the presence 
of pigment granules in the cells of the sebaceous matter. It is an analogous 
state to the chromidrosisj only in the latter case the pigment comes with 
perspiration, in stearrhoea nigricans with sebaceous matter. The treatment 
is the same as in the simple seborrhoea. I now come to 

B. STRUCTURAL DISEASES. 

Hypertrophy of the Epithelial Lining and adjacent structures of the 
follicle is sometimes observed, and then we have what has been called Vitd- 
igoidea — a villanous term. Mr. Wilson calls the disease Xantfielasma, Drs. 
Addison and Gull described and figured the disease in the '^ Guy's Hosp. Re- 
ports," 2d ser., vol. vii., p. 271, and vol. viii., p. 149, which Willan perhaps 
included under the term Vitiligo. It may occur in two forms — " either as 
tubercles, varying from the size of a pin's head to that of a large pea, isolated 
or confluent ; or secondly, as yellowish patches of irregular outline, slightly 
elevated, and with but little hardness." These are mere modifications, and 
are termed Y. plana and Y. tuberosa. It is seen about the face, the ear, and 
the limbs and palms of the hands. The most common form is a yellowish 
patching al^ut the inner part of the eyes'; the disease is symmetrical ; the 
cuticle over the diseased part is unaflected. Eayer figures it at PL XXII., 
fig. 15, and says, ^' On the eyelids and in their vicinity we occasionally observe 
little yellowish spots or patches, very much like chamois leather in color, 
soft to the touch, and slightly prominent, without heat or redness, and often 
f^ry symmetrically disposed." Most authorities regard the disease as an 
hjrpertrophy of the epithelium of the sebiparous glands ; others look upon 



rs5t 



IHBOaDEM OV THS QLAIOM. 



^ the duease ax due to the deposit of a jjeculiarly light^xiioi-ed jiigment. In a 
e exhibited by Dr. Pavy to the Ptitholopcal Society, June, lUfiR, ihvfal- 
lowing were the appearances observed : — " Completely encircling «M"h oye, 

I aad extending for a sjiace of from half to three-C[uartei'B of an inch in browlth, 
a patch of an opaque yellowish color, and itlightly elevated above th« 
BUiTOuntluig skin. Upon the ears there were a number of tuberclea, lookiDg 
certainly to the eye like sebaceouH tumors, Similar tubercles also existed 
Tipon the backs of the hands and arms, and alao on the back and natea. Upon 
the palms of the lianda and palmar BS|>ect of the fingers there was a |>ateh7 
and diffused cream -colored deposit iu the skin. A tabercle removed from 

1 the back of tlie little finger was submitted to raicroBcopifc examinatiuu. The 
deposit jwrvaded tlie true skiu, and occurred in little nodular inasBeHbenmlli. 
These were exoeedtogly tough, and coiiiiiflted of fibrous tissue. Ou being 
Bqtteexed between the forceps an opalescent juic« exuded, whicli was fuunil to 
cont^u B. large number of fat-gi-anules. The cuticle was not involvcnl in the 
affection. It was argued that iiidei>endently of the result of minute exami- 
nation, against its being a sebaceous disease was the fact that it oorrirroil, 
aad in a marked manner, on the palmar aspect of the hands, where no mIm- 
W glands existed. In some cases there is little doubt thai it commeuooB 
in tiw epithelial lining of the sebaceous glands. Jaundice has sometimes 
been foiuid in connection with it. This wan noticed by Dr. Barlow, uid in 
three uf five cases obuervcd by Hebm there was jaundice, Mr. Wilson de- 
nies the connection. I do not know tliat any treatbiejit save the use uf ooia> • 
]iountl tincture of iodine externally, and iron int«nially, lias been uf sc 
but the course would be clear if there were any Uvor disorder presmit. 
It should lie mentioned that cancer may take its riae iu asebaceous g 



RETESTiON OF SECRETION. 



Now thia condition of 
ibre, and often the 




r»e is always accompanied by cliange in thfla 
of the gland, and includes comedones, 
jjn contagiosum, and sebaceous cysts. 

The simplest form is seen in the »trnphidu» 
children, which is nothing more or less than tki 
of little fat glands by fatty matter. As excessive n 
artificially induced in children, disorders the s' 
and produces strophulus, so may the fat glands I 
to action, the secretion of matter being free; i 
cape, and slight distention of the glands oocors. 

lOHEDOKES. 

Comedones, or grubs, contttitnte the orilinary bhtok ^ 
seen on the face of adults auil adolescents, and thej*!] 
iluccd simply by the retention of sebucooua mat 
slight inflammation be excited, then we have acue p 
The akin in both is thickish, greasy ; the seci'etioa^iB n 



SEBACEOUS CYSTS. 255 

and is inspissated ; the dirt collects at the apex of each little grub, and forms 
a black speck or point : the whole fyce — for this is the common seat — may be 
affected. The sebaceous matter can be squeezed out of each follicle, and then 
resembles, according to popular notion, a little maggot ; the mass is com- 
posed of sebaceous matter, epithelial cells, a number of minute hairs, and 
one or more of a species of acanis, called steatozoon (or acaiois) folliculorum, 
see Fig. 26, after Beale. The spores of a fungus, and even puccinia, have been 
found. Comedo is generally regarded as the least expressed form of acne. 

The Treatment consists in curing dyspepsial, amenorrhosal, leucorrhoeal, 
and such-like conditions, which are often present ; exhibiting, in the lym- 
phatic, iron in combination with saline aperients, and cod-liver oiL Locally, 
shampooing the face, or kneading it, as it may be termed — using friction, 
and then ceii^ain stimulating and slightly astringent lotions. Borax is the 
best to begin with. Other remedies are bichloride of mercury, \^dth almond 
emulsion, alkaline washes, oxide of zinc lotion, weak alum lotion. Some 
recommend hypochloride of sulphur ointment. 



SEBACEOUS CYSTS. 

Now in some cases the opening of the follicle of the gland becomes oblit- 
erated, and a cyst forms, filled with sebaceous matter, and analogous to the 
cysts formed in connection with the sweat glands. The simplest form is 
that of little white tumors of roundish shape and opaline aspect, var3dng in 
size from that of a pinVhead to that of a pea, solitary or multiple, and 
generally seated about the eyelids. They contain sebaceous matter. It is 
the acne miliaris of some authors : it differs from molluscum to all appear- 
ance only by the imperviousness of the duct. The treatment consists in 
turning out the contents and applying astringents or nitrate of silver. The 
contents are sometimes calcareous ; the scales becoming '^ impregnated with 
molecular matter ^' (calcareous cysts) ; in. other cases, the contents may be 
fluid (serous cysts). When the tumors are larger and encysted, they are 
called steatomata. These are simply enlarged miliary cysts. Tlieir most 
common seat is the scalp ; they vary in size ; they contain cheesy, fatty 
matter ; .if it be ^' soft and white," the tumors are said to be atlieramcUotts / 
*^ if yellowish, like beeswax," mdicerous / and if white and fatty, atec^vva- 
tous. The cyst wall is thickened and tough, the coats of the gland being 
hypertrophied. 

The best mode of treatment is excision. 

In the above cases of distention of the gland apparatus, the follicular part 
is chiefly concerned, but in other instances it seems that the true gland 
structure takes on an unusually active foi*mation of sebaceous matter, and 
itaelf enlarges, the duct of the gland not being closed, but patent : the whole 
gland enlarging and forming a prominence, not in or beneath, but free on 
the skin, this is 



256 DISORDERS OF THE GLANDS. 



MOLLUSCUM. 

It has been usual to describe two forms of molluscum : the one is a new 
growth from the fibro-cellular tissue, the other a dilatation of the sebaceona 
gland. This confusion of two different diseases is wholly unallowable. I 
have already described the former variety of disease under the head of 
hyi^ertrophies, as Fibroma / the latter, or MoUuseum contagio9iim, as it is 
called, commences as a little white elevation like a minute drop of white 
wax ; this enlarges until it attains the size of a split pea : it may reach that 
of a nut. It is of circular form, firm, white, often flattened at the top» 
where a little depression, which marks the orifice of the follicle, is seen ; 
and it is attached by a more or less sessile pedicle to the surface. The sec- 
tion shows it to be an enlargement and distention of the whole lobules of 
the sebaceous gland. The contents of the little molluscous tumors can be 
squeezed out through the orifice, and consist of soft and whitish sebaceous 
matter. If left alone, these tumors either disappear or ulcerate, or remain 
pretty much in statu quo. The disease is said to be contagious by some ; 
this is denied by others. I have seen a mother and child, and a fiEunily of 
children, affected in such a way as to be inexplicable with our present 
knowledge, save by the contagiousness of the disease. The sac is often 
transparent and shining. The chief seats of molluscum are the &ce, the 
chest, the arms, the genital parts, and the neck. The disease mostly ocean 
in children, but may be seen in adults. 

PatJidogy of Molluscum, — If we examine any of the tumors microeoo[n* 
cally, we find that the whole sebaceous gland is involved and enlarged, the 
follicle being filled with secretion of a fatty character, and the only thing 
found in the mass are cells, which are similar to those of the epithelium 
lining, save that they are piled together one upon another, and are OTal* 
Tliere are fibrous bands running between collections of these cells ; the cells 
are about from ^^^ to pjVir ^^ ^^ ^^^ ^ diameter. They are supposed to 
be the contagious agents. However, I am investigating this point, and re- 
serve my facts for the present. 

The DiagnasU, — ^The disease is easily recognized. The small oval <Hr 
round umbilicated semi-transparent tumor with a central opening, from 
whence seluiceous matter may be squeezed, is unmistakable. In old people 
little fibrous outgrowths are to be met with about the back and chest, bat 
one may readily see that these do not arise from the sebaceous glands. 

The TretUinent o/ Jfolluscum is simple and effective. In those cases 
where it can be done the contents should be squeezed out, and nitrate of 
silver applied to the inside of the tumor. If small, the add nitrate of 
mercury, or }H>tassa fusa solution* may be used. When large, the sac most 
be removed ; and when nuiuen>us, each tumor must be destroyed by cansde^ 
and an astringent lotion useit In old (lersons I have found it necesssiy to 
give quiniue and other tonics for debilitv in connection with moUuscanu 



ACNE. 257 

Horns or Comtia, — When the secretion of the glands Ls abundant and 
pressed together, horns may be formed. 
I need not dwell upon them. 

INFLAMMATORY AFFECTIONS. 

It is generally considered that only one disease ranks here, and that is 
acne ; but I have, it will be remembered, given reasons for supposing that 
furunculi, anthrax, and ecthyma have their anatomical seat in the sebaceous 
glands, although their description will be found under the head of Pustular 
Diseases. I think that Furuncular affections may have to be shifted in any 
anatomical classification to a position under the head of Diseases of the 
Sebaceous Glands. I have only now, however, to desciibe 

ACNE. 

This consists of retention of secretion, together with infiamroation of the 
sebaceous follicles. At the outset there is simply a collection of sebaceous 
matter. This sets up slight irritation (A. punctata) ; congestion of the 
follide ensues in some subjects, and the gland becomes thickened by inflam- 
matory products (A. indurata) ; more or less pus is produced and pent up 
in the follicle ; in some instances the disease assumes an active chai^acter ; 
there may be new formation of vessels and areolar tissue (A. rosac^), and 
in some cases this is so marked as to have led authorities to make an addi- 
tional species — A. hypertrophica. 

AcM simplex is observed in the young of both sexes, especially about the 
time of puberty, on the face and back ; it appears as little hard lumps, 
rising up, so to speak, out of the skin. In severe cases tlie base is hard and 
the apex pustular. {Acne punctata really includes Comedones.) After a 
while the pustule scabs over, and, healing, leaves behind a slight cicatrix. 
A.cne iofiurata is indolent and chronic ; the separate pustules have a very 
hard dusky-red base; suppuration is scantily evolved; the pustules ai*e 
painful, and there is a feeling of tenseness about the face : the derma gene- 
rally is congested, thickened, and dense : it is an exaggeration of acne sim- 
plex. Acne rosacea is rarely seen in young life. It appears sometimes 
to be hereditary. It is common about the nose in women of middle age, 
with uterine troubles. The redness is bright, and the congestion is active; 
in addition there is evidently a new formation of tissue outside the gland 
itself; the veins are varicose, the attempt at suppuration fails; the face is 
much disfigui*ed ; the surface is red, and dotted over with pustules ; the 
integument is thickened; food and stimulants produce gi*eat burning and 
flushing of the face. 

There are two other conditions deserving notice. In both the disease 
commences as an acne. In the one the tissues become hypertrophied, the 
glands enlarge, the skin is red or violet, rough, uneven, shining, and greasy, 
.and little tumors form, which may be sessile or pedunculated. It is some- 
tunes oopnected with intemperance, and is called acne hypertrophica. There 
17 



is an ojipoaite conditioa described by Chuusdit, in which atrophy tokea tl>e 
pluce of the hypertrophy — acae atropliica. I have eeen it otleot tlia MB, 
the face, and the body. It leaves behind little cicatrices. * It haa mow 
alliance with lupua ; there is active gland action at first, and subev4]ttntt 
atrophy. 

Tbe caiisen of acne ai-e soinewhaC obsctire. Acne is common in early Ufe 
— more so in the female than in the male sex. It appears to have a& its 
baaiii congestion of the follicles. This may be brought about by iet«ntiaii 
of secretion, or by a naturally torpid stale of circulation, or by ntflex irri- 
tation. 

The cii'CiiIatioD of the face possesses great eztulability ; It ia liable to 
great fiuctuatiou ; it is very active. These states are acted upon by ut 
t«raal, and not only external, but vaiious internal agencies ; luid uothing b 
mow probable than that some derBugement of the vascular supply will talv 
place. Then the glands are particularly well developed in those aituKtiaBS 
in which acne is wont to occur; they ai-o therefore likely to become foBO- 
tionally dei'anged. We see, then, that all debilitating cause*, aJl local canm 
' of irritation and disonlora of those organs which have a reflex relatdon' with 
the face— e. £f., the stomach, pi-edi^jH>se to the occurrence of the disease, Mid 
act most efficiently where torjwr is a natural feature. Abortive dev«lap> 
nienl of the hairs may disorder the follicles, and produce acne. 

Hence want of cleanliness, stomach derangement, leucoiThcea,menorrluigu, 
cold winds, constipations, the use of cosmetics, physiological changes (■> 
puberty), wunt of nervous power, intemperance, may induce glaudulur con- 
gestion, and HO acne. But when acne is marked and general, what ia tlut 
tendency which ^vea rise to the production of acne? It has been my lot 
to see the subjects of the most severe and obstinate acne I have met witii 
(in young people) die of phthiiU.'s, and 1 cannot but think that lymplutH) 
SVibjects, and those who are of a phthisical tendency, are those must pttNM 
to acne. 

TItf Diaffnotis. — In ecthyma the pustules are lai^e, snrround«>d 1^ KB 
areola, without the induration of acne, and with larger and wlluiratt 

Syphilitic pustules are broader, flatter, shining, and copper-colored ; tiMj 
ulcerate and coexist on parts otlier than the face ; they arc accompouid 
by other forms of eruption, and there is a history of sypliilitic impng- 
nation. 

The 7V««im«»i/.— This varies. Speaking in general terms, we must, fint 
of all, insure cleanliness ; secondly, we must remove any cause of debility 
present, correct menstrual deviations, remove dyspepsia, etc., and es)ieciBlty 
prevent constipation. This preparation is a sine qiiA non. Then, in tlw 
simpler cases, which exhibit little inflammatory action, friction and pnrtlo 
stimulations nmy be had recourse to : borax, soda, and calamine lottono : 
almond emulsion, with bichloride of mercury (two grains to eight ontmo), 
win suffice. In the severer fbnDS much more remains to be done. HikB 



DISEASES OF TBE KAILS. 259 

treats acne as follows : — He gives vapor douches to the face, applies soft 
Boap or caustic potash 3 j* to Oj. of water. In other cases he washes the 
face with soft soap, and at night he applies a paste made of 3 j. of sulphur 
to ^ j. of alcohol or camphorated spirit, by means of a camel-hair pencil. 
This is removed in the morning by means of soap. Cacao butter is kept on 
all day; sometimes he uses bichloride of mercury (gr. v. to 3 j. of spirit), 
with a compress for two hours. At other times he applies, two or three 
times a day, tr. benzoin 3 j*) bichloride of mercury gr. j., and distilled water 
§ vj. I fear Hebra would seriously disagree with English patients. Now, 
first of all, it is necessary that we attend to the state of the general health. 
There is often much debility, which is best met by syrup of iodide of iron ; 
or sulphate of iron, acid, and sulphate of magnesia ; by arsenic, or by acid 
and bitters, according to circumstances. Anaemia must be met with iron, 
strumous tendencies with cod-liver oil, and want of digestive power by the 
mineral acids and bitters. Locally, if there be much inflammation, warm 
poultices, hot- vapor douches, poultices, and warm lead lotion are called for. 
When these have allayed the irritation, absorbents may be used — oxide of 
zinc lotion : oxide of zinc and glycerine or the glycerine plasma. I gener- 
ally prescribe bichloride of mercury lotion, gr. ij. to 3 viij., with borax 3 ss., 
and glycerine, to be fi^quently used ; when the disease is chronic, revul- 
sives are needed — the biniodide of mercury (gr. v. ad § j.) is one of the 
best. A very good plan is to pencil each acne spot with acid nitrate of mer- 
cury once or twice. In acne rosacea, diet and good hygiene are of vast 
importance. If there be many varicose vessels, they may be cut across, as 
recommended by Westerton. The incisions should be never deeper than 2'" ; 
cold water will stay the bleeding, and collodion may be subsequently used 
to contract and heal the incisions. I have generally seen acids, and espe- 
cially pepsin, given internally, do much good. Much has been said with 
r^ard to the efficacy of the iodo-chloride of mercury in acne rosacea and. 
indurata. It is used in the proportion of gr. v. — xv. to ? j. of lard ; it re- 
quires care, as it produces a good deal of iriitation. In the indurated 
forms, it is a good plan to touch the apices of the pustules with acid nitrate 
of mercury : this causes their absorption, often very rapidly. The tincture 
of horseradish is also said to act very efficiently. See Formul® 34, 70-1-4, 
82-3-4, 91-2-3, 100, 115, 121 to 130, 137, 139, 140, 142, 152. 

DISEASES OF THE KAILS. 

The nails become peculiarly rounded in aneurism, cyanosis, chronic in- 
fUmmAtions of the chest, and phthisis. Their structure is altered by the 
attack of certain parasites, as in favus. They are also attacked by psoriasis. 
This has been described. Hebra remarks that they become brittle, thick- 
ened, and broken off in lichen ruber. Sometimes the matrix becomes in- 
flamed, and this appears to be erysipelatous in character. It may be 
primary and idiopathic, or secondary, and often traumatic. The early 
■ympioma are sense of heat and pain, throbbing, and redness just around 



260 DISORDERS OF THE GLANDS. 

the base of the nail of erysipelatous aspect. Tliese increase, the sur&oe 
gets livid, the part beneath the hail inflamed, and assumes a cloudy and 
often a sanious appearance, in consequence of the effusion of blood ; the 
nail loosens, becomes soddened, opaque, and thickened ; and from beneath 
its surface oozes out a nasty dirty fluid. The nail often falls off by and by, 
leaving behind a very tender pultaccous-looking raw surface, which readily 
bleeds. Two courses may now be taken. The part may ulcerate, the finger 
inflame, the bone necrose more or less, and phlegmonous inflammation attack 
the arm : or an attempt at repair is made, after a while a new nail is pro- 
duced, which is short and generally stumpy. The treatment consists of 
local bloodletting, waim fomentations, removal of the nail and other dead 
structures ; the use also of astringent lotions, good and generous diet ; bark, 
with acid or ammonia internally : syphilitic and strumous onychia are no- 
ticed elsewhere. 

In-growing of the toe nail is easily cured by softening the nail, and then 
scraping off as much as possible, so as to thin it in the middle. I have seen 
several instances of vascular corns growing under the naiL 

DISEASES OF THE HAIR. 

The growth of the hair is very intimately connected with nutrition gener- 
ally. Like all other parts of the body, it has a definite term of life, and, if 
not interfered with, would shed itself, to be reproduced at certain times. 
The amount and color of the hair is certainly a very fair index of the tone 
and stamina of any individual. 

Diseases of the hair may be divided into those of Augmented and Dimi- 
nished Formation, Abnormal Direction, and Alteration in Physical Aspect. 

Augmented growth may be congenital and of varying extent, from that of 
little hairy moles to that in the '^ hairy man ^' described by Mr. Crawfurd. 
Stimulation has a tendency to augment the growth of hair, if the formative 
l)ower is normal. During convalescence a reactionary growth oflentimes 
takes place. 

Diminished formation of hair, which is partial or general, compaimtive 
(thinning) or absolute (alopecia), congenital, accidental, or normal (senile), 
may be represented in its different aspects as follows : — 

1. Congenital — (a) partial, (6) general. Tliis is a rare form of diseftae; 

Generally downy hairs stud the surfiEU^ and prove the existence of 
bulbs, though in an inactive state. 

2. Accidental — ia) partial, as in tinea decalvans and other parasitic dis- 

eases ; in cases of wounds, direct injury, and the like ; (^) generml, 
from such as lower the vital tone — e,g,y fevers, syphilis, ^n—mifk^ 
gout, rheumatism, ne\iralgia, fast living, great study, violent emo- 
tions, dys|>epsia, want of cleanliness, over-purgation, local empiiTe 
diseases, wasting of subcutaneous fat, atrophic state of the peri- 
pheral nerves, morphcea (?), and lastly, physiological states — &^., 
hereditary peculiarity, pregnancy, seasonal shedding, defidaaqr of 



DISEASES OF THE HAIR. 261 

formative force inherent in the system, and failure of the mutual 
relations of parts. 
3. N'ormal^ as the shedding of the lunago, and the loss of hair in old 
age (calvities). 

When the hair is lost entirely from a part, this is called alopecia, or 
baldness. Parasitic disease is the most usual cause of localized baldness ; 
syphilis, violent emotion, atrophy of the scalp (?), and senility, are most 
efficient in producing an absolute or great amount of baldness. The other 
conditions noticed above usually give rise to thinning, not absolute loss or 
baldness. Circumscribed baldness is considered under the head of 7\iiea 
tlecalvans. The total loss of hair is sometimes seen in early life. I have 
had a boy under observation who has not a vestige of hair on his scalp ; he 
was at the time I saw him about four years and a half old ; no cause could 
be assigned for the loss of hair. Another instance is that of a young lady 
about thirty. Now, in some instances of complete loss, the baldness has 
commenced at one 8|)ot and travelled over the scalp. In other cases the dis- 
ease commences as a general thinning ; '^ handfuls '^ of hair " co7fie otU^'^ and 
suddenly the whole is lost. Various theories have been suggested. You 
Barensprung believes that the cause is a failure in the nerve-power. It is 
clear that the formative power suddenly fails, for in the early condition the 
follicles are distinct, and the skin is normal. It is true that it presently 
becomes thinned, hard, white, shining, insensible somewhat, and the follicles 
waste ; but these changes are sometimes the necessary consequence of the 
inactivity of the hair-forming apparatus, and not the cause of the loss of 
bair. It appears to me that in some of these cases the hair dies from want 
of nutritive pabulum, as in syphilis ; in others, in consequence of the cessa- 
tion of the*normal reproductive function of the formative apparatus. The 
bair comes to its natural period of existence, and no attempt is made to re- 
form it. Violent grief, great mental labor, and anxiety, are determining 
causes of this form of baldness. It is pretty rare. 

Senile baldness, or calvities, is due to an atrophy of the structure gener- 
ally ; it commences on the ci'own of the head, the hair first turning gray ; 
the scalp is dry, thinned, loses its subcutaneous fat, and the follicles be- 
come indistinct. In some people this change takes place at an early age ; 
it is either an hereditary or physiological peculiarity. 

Greneral thinning of the hair, it is easy to understand, is most likely to 
occur under conditions which lower the vital energy of the patient. The 
scalp generally is scurfy and dry. This is in all probability due to the 
sluggish action which goes on. The usual sebaceous matter is not secreted ; 
the follicles become choked by retained fatty and epithelial matter, and the 
fimnation of the hair is interfei*ed with. This is also the case in eruptive 
disoMo and in syphilis. 

The loss of hair in all these cases is an evidence of the working of some 
debilitating cause ; it is not remediable to its most perfect extent without 
the Qie of general remedies — not by the employment of local stimulation. 



262 DISORDERS OF THB GLANDS. 

The hair in cases of thinning and baldness is often dry, brittle (crisp), 
and twisted or split up. This results from the peculiar absence of mois- 
ture ; in its turn from the diminished activity of the circulation of the 
scalp ; in its turn again, from the genei*al debility of the system. 

The various other alterations in physical aspect come under the head of 
Parasitic Disease. , 

2^ he Diagnoais. — Senile baldness commences with the hair becoming 
gray ; it occurs of course in old people, at the vertex of the scalp first of 
all. The structures generally waste ; there is little subcutaneous fat ; the 
follicles are indistinct ; the circulation is diminished, and the scalp is white, 
thin, and shining. 

Alopecia from parasitic disease occurs in the young chiefly, and is pre- 
ceded by signs of local irritation. It commences not at the vertex but at 
the side of the head generally ; the hair Ls not gray, the scalp is natural ; it 
is not wldte, thin, and shining, but the follicles are distinctly visible ; the 
circulation is always pretty active. In some cases there ai-e peculiar fea- 
tures present, in consequence of the rapid and free growth of the fungus — 
e. g,y favus, tinea tonsurans. Parasitic disease gives rise to partial loss ; 
debilitating causes to general thinning ; syphilis sometimes to general loss, 
but mostly temporary thinning. 

The Treatment, — In the cases of total loss, much good may oftentimes be 
done. In the first ])lace, all syphilitic taints I'equire detection and specific 
treatment ; the hair will assuredly grow if a sy|)hilitic taint be treated. 
Then debility of all kinds must be removed ; and this is a matter of some 
considerable nicety, i-ules for which cannot be laid down. It is customary 
to give arsenic in these cases, and it is requisite that the student should 
know that one of its s])ecia) actions is sui>posed to be tlie promotion of the 
regrowth of the hair. I prefer to treat the patients not by specifics but on 
general princi])les ; and so with i*egard to the cases of general thinniug. 
Dyspepsia has appeared to me to be a very frequent source of evil in the 
latter class of cases ; it has assumed, too, a most determined and inveterate 
form, resisting acids, alkalies, bitters, and yielding at last to a long course 
of pepsin porci. Iron and tincture of nux vomica are useful tonics in the 
'* nervous '^ cases. With regard to local measures : — In the cases of abso- 
lute loss, which occur from trouble, or rather a failure of the reproductive 
function of hair-forming apparatus, local stimulation is the sine qud non 
whenever any downy hairs are visible ; if these be absent, the scalp atro- 
phied from disease, and white and shining, little good will be done, though 
I have succeeded even here. Repeated blistering must be adopted, and 
stimulating washes used. If there be oedema, or any tension, though the 
follicles are distinct, tincture of iodine applied over parts of the scalp every 
two or three days is of service. Shaving the downy-haii*ed scalp is also 
beneficial. Nine out of ten affirm that this does harm. I know to the 
contrary ; it should be done once a fortnight regularly for a while. In the 
cases of genei*al thinning, the plan of stimulation requires modification. The 



DISEASES OF THE HAIR. 263 

general state of nutrition is below par ; and hence the local also. The 
scalp is not healthy ; it is dry, scurfy, irritable. We should first of all try 
and get it into a soft and cleanly condition by frequent ablution, the use of 
glycerine and lime-water, or olive oil and lime-water, used night and morn- 
ing. Then we may recommend local warm vapor douches, with gentle 
firiction and galvanism. When the system is under the influence of tonics, 
we may employ local stimulation with the best results. Some teach that 
greasy applications should be avoided. As a rule, this is good advice. 
Certain ordinary pomades, cosmetics, and the like, on account of their veiy 
rancidity, do harm ; the olive-oil and lime-water compound is not open to 
this objection. Tincture of nux vomica I have found the most efficient 
local remedy, in combination with distilled vinegar, and tincture of can- 
tharides. 

When thinning of the hair is the result of eruptive disease, it is due to 
debility, and must be treated upon ordinary principles. 



SUMMARY. 



In the chapter on Classification, in the early part of the work, I gave only 
the Iieadiugs of the different classes of skin diseases, and omitted to fill in 
details — viz., to name and place the individual diseases in their proper posi- 
tions in these several groups — under, for example, eruptions of acute specific 
diseases, diathetic diseases, hypertrophies, and atrophies, diseases of the glands, 
etc. I thought it best to reserve these particulars until I had given the 
descriptioli of each separate disease ; the reader would then be the better 
able to comprehend the complete arrangement, and the somewhat unusual 
position assigned to certain aifections which I have come to regard as |k>s- 
sessing a dififerent nature and (>athology from those signified by the position 
which they have hithei*to been^assigned in other systems of classification. I 
now proceeil to complete the classification which was given in outline in 
Chapter I., and in so doing I shall under each group refer to the novel points 
of pathi>li>gA- contained in the various preceding chapters. The result will 
be a sununary of the ]>athological contents of the book. I should repeat 
that the classificsition is made in accordance with the principles laid down in 
the nomenclature n^fK^rt of the College of Physicians, which all are bound to 
ailopt. The following are the diseases of the skin with which dermatologists 
have to deal : — 

1. Eruptions of Acite Specific Diseases, 

Including mriV)/^, vaccinia^ mricfilay typhus and typhoid^ rtf^eo/a, ruMlaj 
or anomalous exanthem, stttHatinaj eryitijifias. ifengti^^ or dandy fever, 
nuuiifnnnt puMuU (duo to a s|>ecific animal \'inis), ^•(•ii4/<f r#, and ^Wry. 
[Si>me authors place frainlHt^ia here. See remarks under Diathetic 
Dis«^ases.] 

2. IxK*AL Inflammations. 

A. Ervthematoi'S, including erythema ^ intfrtri'^o^ rofeda^ urticariay and 

iN(^/iWii#i/ rtw-W. [ Pellagra is placeii here by some writera. See Dia- 
thetic Disea^\s. ] Si^me think urticaria should be classed with neurotic 
diseases. 

B. Catarrhal^ or erzrma^ as defined by Willan« an infismmstion with aero- 

purulent di&charge as its main featun^. It corrpspomi» in the skin to 
CHtarrhal inflammation of the mucous membrane, and includes ecawma 
Wwi/t/^x, ni^rtffH^ iiujftit/iniyff*^ and the locsl varieties of these three 
forms. 



LOCAL INTLAiatATTOHS. 



S65 



. Plastic or " Fibroub," ineluding tlie disease lirkmi, as defined by WiJIan, 
and its rarieties, simplec, cireumscrlpCttti, gyratv-H, ngriiM, rtiher of Helira, 
so called atrophviiu pruriffinosu*, liekmi in childreu, which is classed 
with different diseases under the tenn strophulus, lidtKn pitarin, and 
the mixed foims L. Uvidus, urticaCria, ecze-malodea, in which purpura, 
urticaria, and eczema respectively occur. [Lichen ruber involves the 
hair-follicles very distinctly, and in addition, the papiitaiy layer of the 
skin ; hence it fairly ranks with lichen. I believe that stroiihulun, as 
defined by most authors, includes simple lichen occurring in infants, a 
sebaceous disease (S. albidiis), and congestion and inflammatiou of the 
perspiratory follicles ; and I have broken up strophulus into these foiiua 
of disease, placing its components in their projier place. Lichen tropi- 
cus b a disorder of the perspiratory apparatus. Lichen pilaris may bo 
included under the head of lichen, it being understood that the hair- 
fbllicles are specially the seat of fibrous inflammation, 8e« DiseaMca of 
Hair-Follicles. Lichen sci-ofiilosus is not a Kchen, it begins os a pity- 
riasis of the hair-follicles, aud is followed or complicated by acne ; it 
occurs in sti-iimous subjects, and should be ri'garded as disease of the 
liair-fullieles and the related sebaceous glands.] 
. SUPPi'HATlVE, including impetigo, eet/iyma, and futtineuJivr affections, 
and (?) certain endemic diseases, such as Delhi boil. [If the pi-imary 
anatomical seat of furunculi he the sebaceous glands, funinculi would 
rank here as suppui'ative inflammation, specially involving the sebaceous 
glands, and tbe disease would be also named under the head of Dis- 
eases of the Sebaceous Glands. Imjictigo contagiosa is a form of dis- 
ease distinct from ordinary impetijjo {see p. 94). For the present, 
Delhi boil, Aleppo evil, Biskra bouton (figured at p. 100) are placed 
here. It is a question whetliur these affections, together with fram- 
htesia, — all of which are allied and produced by enilemic influences 
acting generally on the system,— be not classifiable under the head of 
constitutional or diathetic diseases. Pustula maligna and glanders are 
clearly correctly placed with acute specific diaeases.j 
■ lE. Bullous, including herpp^ bm^ pemphigug. [There is a growing incli- 
nation to runk these two diseosea under the head of neurotic diseases, 
and I may call attention to a singular featui'e in their clinical history 
bearing U])on this point. They exhibit changes in the skin which are 
not only those exactly which we should expect to follow an alteration 
in the calibre of vessels, the result of nerve paresis, but occur in con- 
nection with a comparatively passive state of the tissues themselves. 
This seems to indicala that the blood and tissues are not the originators 
of disease or actively iuvolved aa in oilier inflammations. There is 
rapid escape of serosity, after congestion, and cei-tain changes in the 
exuded fluid. The fluid becomes opaque and dries into ci-UHt«, changes 
which are due to the inherent properties of the outpoured fluid, aud 
ate independent of any active infl.uence3 exerted by tbe tissues of the 



266 snuMAJtT. 

derma. In oriUnory iaflatninationa, the tisBuea take on sped&l actiott; 
there is cell-growth auil disordered cell-nutrition of an iifitiTe kind, 
which accounts for the continuauce of diKcase; Rtich an intln«DC« is 
abseut in herpes and petnphigua. I think the facts inTolved in the 
contj-ast which I have attempted to indicate arp cei'tjunly g 
favor of the specially neurotic nature of herpes and jtemphigua.] 

3. Diathetic Diseases. 

A. Strumous, including gcrofvloderma and Input. 

B. CANCEBOfs. — £pitheluana and rodent ulcer. 

C. Syphilitic. — Secomlwry and tertiary disease. 

D. Lepbous. — Elejihanliasit ffnecorvmi. [It ia thought by eoroe t 

phiea, keloid, scleroderma, etc., are allied to elephAutiasis.] 

E. Ai.PHOt'8. — Lepra vulgarU. [Might not Pellagra, Frambteda, ] 

boil, Aleppo e\-il, and Biskra boutnn, inasmuch as they are due to ft 
general mal-nutiition produced by climHcteric or endemic influences, 
be classed under the head of Diathetic Diseases?] 

4. HVPERTRUPHIES AND ATHOPHI 

The diseases that are found under this head are simple enougl 

The hyitei-tiwphieB are those of ( 1 ) epithelium — ex., pUi/rioM, i 
calloaitua ; (2) the papillie, a^ in tcarts ,• (3) the vascular a 
as in nirvi ; (4) the tibrous tissue of the derma, as in kdoid, t 
derma, morj)luea,jibrorna, biitneima, and dermalolyslg. 

Under the head of AtropKir-s, we have only atrophia rtili*. 
I.astly, a sub-head, entitled Developmental Diseases, ai)i>eani in the 
work, BO as to include ielilhyoeit and xcrodenna.. 
[I am by no uieans satisfied with the arrangement of this group, but 
tliink it the best that can be made in the present stal« of our {nithulogical 
knowledge. In the first place, though simple pityriasis might rank witfa 
hypertrophic ufTectious, one variety, P. rubra, is more truly an iuflammft- 
tory affection of the true skin, and should rank with iiiUammntory ufleo- 
tiona ; it is indeed a deruiatltis. There is a general relationship liet^reen 
morphoea, fibroma, bucnemia, and Bcleroderma, in the fact that the diseaaea 
conmst of change in the hbro-cellular tissue of the skin. In murjihoEia the 
hypeqilosic growth of tissue is not well marked, but its relationship to 
scleroderma (and other tibro-celliilar degenerations) is shown in tlie fitct of 
its occurrence as a pait of, and oftenlimes apparently as the early stage at^ 
that disease. A similar condition to morphiea occurs in leprosy. The 
most novel point in relation to these diseases of the fibroun element of ihfi 
vkin is the probable participation of the lym|)hatic Byirt«m in their causa- 
tion. The degree of ilepravity or degeneracy in the " lymph " vnrioa in 
each of these diseases, and the material of morphtea seems to be the Carlheat 
removed from true fibrous tissue, with which, however, it has affiuitiee. 
Bee remarks on the group, p. 184.] 



DISEASES OF THE GLANDS AND APPENDAGES. 267 

5. HiEMORRHAGIO AFFECTIONS, 

Embracing /nerpura and scurvy, 

6. Neurotic Diseases, 

Including pruritus and prurigo. [If herpes and pemphigus are allowed 
to be included here, the term and group ^' bullous inflammation '^ may 
be rejected. True prurigo I regard as primarily a neurotic disease ; 
pediculi are often present, and produce certain " bites,'^ but otherwise 
they act merely as local irritants, and could not produce the atrophy 
of the skin, &c., seen in prurigo, unless the innervation of the skin were 
primarily at fault.] 

7. Chrokatooenous Diseases. 

There are two chief diseases : leucoderma, or deficiency of pigment ; and 
melanoderma, or excessive pigmentation. 

8. Parasitic Diseases. 

A. Animal or Dermatozoic, including scabieSy and morlrus pedicutaris^ 
or phUieiriasiSy and affections associated with the chigoe, the dracun- 
culus, the leptus, fleas, bugs, gnats. [In regard to the relation be- 
tween jiediculi and prurigo, I may refer to what has been said at pp. 
236-7.] 

B. Vegetable, or Dermato phytic, including tinea favosa^ tinea ton- 
suraiis^ tinea keriony tinea drcinataj tinea decalvanSy tinea sycosis^ tinea 
versicclaTy tinea tarsi, matlura foot, and onychomycosis, 

[I affirm the truly vegetable nature of ^' vegetable parasites : '^ that they 
will not flourish on really healthy surfaces, that growing fungi alone pro- 
duce the dry, brittle, and split up hairs, and the damaged epithelial cells, 
seen in the group tinete. Fungi act also as local irritants. Kerion, a 
modification of tinea tonsurans, in which the sebaceous follicles are prob- 
ably involved, is described at p. 224. There is a paiusitic sycosis, but in- 
flammation of the hair-follicles may occur, of course, as a non-parasitic dis- 
ease. One of the forms of so-called eczema marginatum is parasitic, and 
here I agree with Dr. Anderson. True tinea decalvans is parasitic. There 
are other instances in which the hair is lost over circumscribed [)atches, 
from atrophy and syphilis. Madura foot, which is figured at p. 248, is now 
recognized as a parasitic disease.] 

9. Diseases of the Glands and Appendages. 

Sweat Glands. — The disorders may be arranged thus : — 

A. Disorder of Function: including hyperidrosis (excessive sweating), 
anidrosis (diminished perspii'ation), osmidrosis (change in odor), and 
chromidrosis (change in color). 

B. Structural Disorder : miliaria and sudamina (congestive disorders), 



268 SUMMABY. 

lichen tropictts (folliculitis), atrophtUtu (inflammatory), hydro-adeniti$ 

ft 

(suppurative), and ci/stSy due to follicular obstruction. [I have placed 
lichen tropicus under the head of inflammatory disorders of the sweat- 
follicles, and some of the cases that make up the strophulus of children 
are instances of folliculitis.] 
Sebai'EOI's Glands. — As in the case of the sweat glands, we may divide the 
diseases of the fat glands into two groups. 

A. FrNCTioxAL: including stearrhcea or sehorrhcsa (increased secretion), 
asteatodes (deficient secretion), and aUasteatodeSy or alteration in the 
character of the secretion. Retention of secretion is usually accom- 
panied by alteration of structure ; it is described under the latter head. 

B. Structural: diseases of the lining membrane— >ex.,/>»^yrian9, r»^7t- 
gouieGy retention of secretion and its consequence, comedo^ seb€u^eaus 
cystSy nwUuacum contagiosumy and lastly congestive diseases and inflam- 
matory disorders — <tcnej furuUctiiu^y &c, [I have described vitiligoi- 
dea as a disorder of the epithelial lining of the glands. There is reason 
to think that the anatomical seat of furunculus is the sebaceous 
gland of the skin, a boil being a suppurative inflammation of the gland, 
i have, however, placed furunculus under the head of suppurative in- 
flammation of the skin, specifying the probability of its involving the 
sebaceous glands. In the lichen scrojulonu (or scrofiilosomm) of 
Hebra, the anatomical seat of the disease is first of all the hair folli- 
cles, and subsequently the sebaceotis glands; it occiurs in markedly 
strumous subjects. See p. 81.] 

Diseases of the Hair. — For tabular statement of diseases see p. 4G9. 
[Lichen pilaris is ^^ fibrous or plastic ^' inflammation of the hair follicles. 
See p. 81. Lichen scrofulosorum commences as a pityriaaiB of the 
hair follicles, and involves after a time the related sebaceous glands, 
giving rise to a sj^ecies of acne, p. 82. It is not a lichen at all.] 
Nails. — See p. 259. 

I hope this summary, founded^ as I have said, upon the classification of 
diseases rvcommendeil bv the College of Phvsicians in its nomenclature 
report, will indicate the present s^^ate of knowledge in regard to skin dis- 
eases, and es|>ecially the novel iH>int8 in this work. 



FORMULARY 



BATHS. 

1. The Brick Vapor Bath, — Mr. Grantham's simple mode of applying 
steam vapor. '^ Boil two gallons of water ; at the same time put into the 
fire half a brick, which must be heated to redness ; have a cane-bottomed 
chair and a hot bath to the feet, with a lai'ge blanket in the room ; put the 
boiling water into an eai-then pan, and place it under the chair : then put 
the red-hot brick into the pan. The patient is to be seated on the chair in 
a state of nudity, with the feet in the foot-bath, and then to be covered, ex- 
cepting the head and face, by the blanket. By these means the steam is 
kept up on the surface of the body for the space of fifteen or twenty min- 
utes ; after which the patient is to be well dried and retire to a warm room, 
or be placed between the blankets.^' If a sulphur bath is wamted, ** boil 
six ounces of sulphur fifteen or twenty minutes in the two gallons of water ; 
or, if an ammonia-bath is required, merely put two ounces of the strong 
liquid ammonia into the water just before the brick is introduced.^' 

2. A Modified Plan is the bath invented by Messrs, Benham and Froud, 
of Chandos Street, W.C., called the Portable Oriental Vapor Bath. The 
price is about thirty shillings, and there is apparatus for all kinds of fumi- 
gation. If a sulphur-bath is to be used, the quantity of sulphur should be 
half an ounce : the mercurial agencies were noticed under the head of the 
Treatment of Syphilodermata. 

3. Mr, Henry Lee^a calomel fumigating bath is made by Savigny, in St. 
James's Street. 

ORDIKABY BATHS. 

The quantity of water in a bath is estimated at 30 gallons, and the 
amounts of medicinal substances stated below have reference to this quan- 
tity. 

4. EmoUients, — Bran lb. 2 to lb. 6, potato flour lb. 1, gelatine lb. 1 to lb. 3, 

linseed lb. 1, various herbs — e, g,^ mai^shmallow, lb. 4, size lb. 2 to lb. 
4, to 30 gallons of water, as stated above. 

Use in aU erythematous and itchy diseases, syphilodermata in the 
early stage, licheuy lepra^ etc, 

5. Alkaline, — Carbonate of soda | 4 to | 8, carbonate of potash 3 3 to 

^ 6, or the same, and in addition borax 3 2 where there are many 
crusts to be detached. Borax or sulphur, of each | 2. 



270 FOBMULARY. 

Use in eczema, urticaria, lichen, and prurigo, where there is much 
local irritation. 
C. Acid, — I 1 of nitric or muriatic, or a mixture of nitric acid^- ^ ^ or 
more, with hydrochloric acid, in like quantity, to 30 gallons of water. 
Useful in chronic lichen and prurigo, 

7. Iodine, — Iodine 3 i, iodide of potassium, ^ i, with | 2 of glycerine; or 

iodine 3 1 or more, with | 1 or 3 2 of liquor potasses, to .30 gallons 
of water. 

Use in scrofulous enqytions, in syphilis, and in squamous diseases, 

8. J^romine, — 20 drops of bix>mine, with § 2 of iodide of potassium. 

Use as the iodine. 
Sulphuret of Potassium, — 3 4. The balneum sulphuris co. of Startin is 
made with 3 2 of sulphur (precipitated), ^ 1 of hyposulphite of soda, 
and 3 ^ of dilute sulphuric acid, with a pint of water, added to the 
usual 30 gallons of water. 

Use in itch, in chronic eczema, lichen, and psoriasis, 

9. Mercurial, — Bichloride 3 1 — 3 with 3 1 of hydrochloric acid. Bini- 

odide of mercury 3 1> ^'ith 3 2 of chloride of sodium. 

Use in /)t7yri/i^ rubra and the st/philodermata, especially with til- 
ceratiou. The Pui*ton springs in North Wilts are bromo-iodated 
and sulphated w^aters, having a temperature of 58^° F., and would 
appear to be veiy useful in strumous subjects. 

CAl'STICS. 

10. Iodine, — Iodine 3 i, iodide of jxitassium 3 1| distilled water 3 5. 

Use in glamhdar enlargements, lupus, 

11. titrate of Silver, 3 2 to 3 1 of spirit of nitric ether. (To be kept ex- 

cluded from the light.) 

Use in the chronic forms of ergtltema, eczema, and lepra vulgaris^ 
ringworms, 

12. Chloride of Zinc (Startin). — (Chloride of zinc 3 ^> chloride of antimony 

3 2, starch 3 1, snd glycerine q, s. 
Use in ulcerous and tuheradous affections. 

13. Arsenica^ (Startin). — Calomel 3 2|, bisulphuret of mercury 3 2, and 

arsenious acid 3 1* 

Use in luptis, scrofulous ulcers, and syphilis, 

14. I^enna Paste, — Unslaked lime and caustic potash, of each equal parts ; 
when used, mix with alcohoL 

Use as above. 

15. Bicganide of Jfemirg, — gr. 2 or more to f 1 of water (Burgess). 

Use in acne rosacea / to be painted on for two or three minutes and 
then wijH*d off. 

16. Binioilide of Mercury,— gr, 10 to gr. 20 to 3 ^ of glycerine. 

Use in luptis especially. 



FOBMULABY. 271 

17. Plencks. — Alcohol and acetic acid, of each 5 i; bichloride of mercury, 
alum, camphor, and carbonate of lead, of each 3 i« 

XJse in syphilitic warts ; pencil twice a day. 

18. Savin (Langston Parker). — Powdered savin, bichloride and nitric oxide 
of mercury, of equal parts. 

Use in condylomata and wa/rU, 

19. Coster* s, — Iodine 3 2, and colorless oil of tar 3 1. 

Use in ringworm in the early stages/ one or two applications suf- 
fice. 

SOAPS. 

20. Hendrie*s Dispensarjf petroleum soap. 

Use in eczema. 

21. Juniper'tar Soap (recommended by Velten of Aix-la-Chapelle). 

Use in the sqtuxmous diseases especially. 

22. The common Soft (potash) Soap^ used in chronic infiltration — «. </., 
lichen circumscriptus or chronic eczema. It may be dissolved in boil- 
ing water, § 1 of the soap to ^ 2 of water, and scented with some aro- 
matic oil. 

23. The Sulphur Soapy of use in scabies and prurigo, 

24. Sapo Zaricis (Moore, Dub, Hosp, Gazette, March 15, 1859). — Wheaten 
bran | 4, glycerine § 3, white curd soap | 24, extract of larch bark 
^ 6, and rose-water ^12. 

Use in pityriasis, psoriasis, chronic eczema, and fierpetic eruptions. 

25. Pearls transparent Soap, — The best soap made. 

26. There are many other kinds of soap, but I am not in the habit of using 

them very much^-ex., sulphur, carbolic acid, oxide of zinc, etc. 

Soaps, and other preparations from the formulie contained in this work, 
are beautifully made, and kept on sale by Messrs. Caswell, Hazard & Co.> 
the well-known Druggists of New York. 



272 FOUMCLARY. 



* 



ASTRINGENTS. 



27. 5 Tannic acid 3 ij. 

French vinegar § «8. 

Distilled water | viias. 

M. Ndigan, 

28. ]J Tr. krameria ^ 3 ij. 

Creasote .' gtt. viij. 

Pnissic acid, dilute gtt. viij. 

Distilled water *► . . 5 iv, 

M. Ndigan. 

29. :^ Opium gr. viij. 

Creasote gtt. x. 

Lard S ij. 

M. Use in prurigo and lichen. Ndigan. 

30. IJ Tincture myrrh. gtt. xxx. 

Oxide of zinc gr. xx. 

Cold cream § j. 

M. Use in prurigo, erythema, and lichen. Ndigan^ 

31. Ti. Borax 3L to 3i. 

Glycerine | j. 

Rose-water • 3 viij. 

M. Use in squamous diseases. 

32. 5 Oxide of zinc 3 ij. 

Glyceiine 3 ij. 

Lead-water 3 iss. 

Lime-water 1 vj. to viij. 

M. Use in the secretory stage of eczema, in acne, 
in lichen, foul ulcers, impetigo, and hei*pes. 

33. 5 Dilute hydrochloric or nitric acids 3 ss. to 3 ij. 

Sugar lead gr. v. to x. 

Water 3 vj. 

M. Use in eczematous and lichenous affections. 

34. ^ Alum 3ij. 

Infusion roses 3 xvj, 

M. Use in acne, pityriasis, and eczema (sine 

crustis). Cazenave. 



FORMULAEY. 273 

35. 5 Sulphate of copper 3 j. 

Sulphate of zinc §88. 

, Distilled water | xvj. 

Cherry-laurel water | ss. 

M. Use in mentagra. Dupey, 

SEDATIVES LOTIONS AND OINTMENTS. 

36. 5 Carbonate of soda 3 ss. 

Conium juice 5 j* 

Elder-flower water | j. 

M. 

37. 5 Bicarbonate of soda 3 j. 

Glycerine 3 iss. 

Elder-flower water § viss. 

38. 5 Biborate soda 3 ij. 

Cherry-laurel water | j. 

Elder-flower water 3 xj. 

M. Ndigan, 

39. Ijl Soda or potash 3 ij- 

Water § vj. to § viij. 

M. Uses — Either of the above is useful in the 
early stages of vesicular and papular dis- 
eases to allay itching. 

40. 5 Borax | ss. 

Sulphate of morphia g^'* XJ* 

Rose-water 3 viij. 

M. Use in pruritus vulvae. Meigs, 

PRUSSIC ACID. 

41. 5 Bichloride of mercury S^' h 

Prussic acid, dilute 3 j. 

Emulsion of almonds %\j, 

M. Use in itching, in lichen, in the syphiloder- 
mata, and pruritus. 

42. 5 Prussic acid, dilute 3 j. to 3 ij. 

Infusion of marshmallow 1 v. to | viij. 

M. 

43. ]$ Acetate of ammonia. ; . | ij. 

Prussic acid, dilute 3 j. 

Tincture of digitalis 3 iij* 

Rose-water § v. 

M, Thomson. 

18 



274 FORMULARY. 

43. IJ Pnissic acid, dilute 3 ss* to 3 j. 

Water o U* ^^ 1 ^U* 

M. Use in the priii-igo of old people. 

44. 5 Boi-ax 3 88. 

Pru8sic acid, dilute 3 ij. 

Ro8e-water 3 viij. 

M. Use in lichen agiius. 

N^digan. 

45. 5 Cyanide of potassium gr. vj. 

Cold cre^m 3 j. 

Cocliineal gr. j. 

M. Use in pruritus urticaria. 

Anderson, 

4G. IJ Cyanide of potassium. . gr. v. 

Sulphur 3 S8. 

Bicarbonate of potash 3 ss. 

Cochineal gr. j. 

Lard § j. 

M. Use in eczema with pruritus. 

Anderson. 

47. IJ Cyanide of potassium gr. xv. 

Water 3 viij. 

M. Use in pudendal irritation, lichen, and pru- 
rigo. (To be kept in a dark place.) Hardy, 

CHLOROFOKX. 

48. IJ Chloroform ITL vj. 

Cucumber cerate 3 j. 

M. 

49. 3 Carbonate of lead 3 ss. 

Chlorofonn Til iv. 

Cold cream 3 j. 

M. 

50. IJ Chloroform Til \i\], 

(ilycerine 3 j- 

Simple cerate 3 vij. 

Cyanide of potassium gi*« iv. 

M. Xeligan, 



FORMULARY. 275 

51. 5 Chloroform 3 j. 

Glycerii^e 3 iv. 

M. Duparc, 

52. 5 Glycerine %i]. 

Bichloride of mercuiy gr. iss. 

Chloroform TTl xx. 

Rose-water 5 \j* 

M. Use in itching, in papular and vesicular 

diseases, and urticaria. * Surgesa, 

BELLADONNA. 

53. 5 Extract belladonna 5 ^« 

Hydrocyanic acid, dilute 3 ss. 

Glycerine ? j. 

Water 3 ^iv. 

M. Use diluted in papular and phlegmonous af- 
fections. Startin, 

DIGITALIS. 

54. IJ Tincture of digitiUis 3 ij. to 3 iv. 

Glycerine § ss. 

Rose-water 3 vj. 

M. Use as a lotion in prurigo of purely neu- 
rotic character. 

LIQUID PITCH. 

55. IJ Pitch 3j. 

Extract of opium 3j. 

Lard ^ j. 

M. Use in obstinate prurigo. I^uparc, 

VARIOUS. 

56. IJ Sweet almonds 3 j. 

Orange-flower water 3 ij. 

Rose-water 3 viij. 

Make an emulsion, then add 

Muriate ammonia 3 j. 

Tincture benzoin 3 ij. 

M. Use chiefly as a cosmetic. 

57. 5 Carbonate of lead gr. iv. 

Glycerine 3 j. 

Simple cerat« 3 j. 

M. Use in erythema. 



i 



276 FORMULARY. 

58. IJ Solution of diacetate lead 3 j. to 3 ij. 

Infusion of marshmallow § xvj. 

M. Use in lichen and chronic eczema. 

£urffesf, 

59. IJ Solution of acetate of ammonia 5 y* 

Alcohol 5 88. 

Rose-water 3 iv. 

M. Use in lichen. 

Surgess. 

60. IJ Protochloride of lime 3 ss. 

Almond oil 3 ij. 

I^rd 3 iij. 

M. Use in papular itching. 

Biett. 

9 

62. IJ Acetate of zinc gr. ij. 

Rose-water 3 j- 

Cold cream § j% 

M. Use in erythema and herpes. 

63. 5 Aconitine gr. j. to gr. v. 

Lard |j. 

M. 

CAMPHOR. 

64. IJ Camphor 3 ss. 

Alcohol q. 8. 

Oxide s^inc 

Starch 

M. Use as a powder to allay burning heat of ec- 
zema. Anderson. 



; [ aa !j- 



65. IJ Camphor gr. viij. 

Tincture conium , . . . 3 ij« 

Simple cerate 3 j. 

M. Ndigan, 

66. IJ Camphor 3 ss. to 3 j» 

Alcohol 3 j. 

Borax 3 ij. 

Rose-water | viij. 

M. Use in pruritus, eczema, and erythemata. 

67. IJ Powdered maize 3 iv. 

Oxide zinc 5 J* 

Calamine 3 88. 

M. Absorbent powder for excoriated surfaces. 



FORMULARY. 277 

STIMULANT AND ABSORBENT REMEDIES. 

67. 5 Soft soap 5 J- 

Boiling water 5 ^XJ* 

Perfume to taste. 
M. Use in the second stage of eczema to coun- 
teract the infiltration. 

67. IJ Tar \ 

Alcohol 5- fiii 3 j. 

Soft soap ) 

M. Similar to Hebra's TV. Saponia Viridis cum 
pice. Used in eczema. 

68. 5 Alcohol \ 

Oil cade t Aa | j. 

Soft Koap ) 

Oil lavender 3 iss. 

M. More elegant than the fonner. Anderson, 

69. IJ Camphor gr. x. 

Glycerine TH x. 

Fresh lard 3 j. 

M. Startin's camphor ointment. Use in erethe- 
matous, vesicular, and squamous diseases. 

BORAX. 

70. U Boi-ax.... \ ^^^ 

Carbonate of ammonia ) 

Glycerine 3 j. 

Hydrocyanic acid, dilute 3 iij. 

Distilled water 3 xvi. 

M. Use in vesicular and sebaceous diseases, di- 
luted from one to four times. Startin. 

71. IJ Borax 3ij. 

Oxide zinc 3 j- 

Solution subacetato lead 3 y. 

Lime-water 3 vj. to 5 vJij. 

M. Use in eczema and herpes. 

72. 5 Borax 3 j. to 3 ij. 

Glycerine 3 j- 

Lard 3 j. 

M. Use in parasitic diseases, eczema, erythema, 
intertrigo, and lichen. 

MERCURIAL. 

73. 5 Calomel 3 j. 

Lard 3 j. 

M. Use in herpes, psoriasis, pruritus vulva?. 



278 FORMULARY. 

74. IJ Protoiodide of mercury g**. ij. to gr. xv. 

Lard | j. 

M. Use in acne. Sardy. 

75. IJ Bicyanide of mercuiy gr. v. to gr. x. 

Lard 3J. 

M. 

76. 5 Biniodide of mercury gr. v. to gr. xx. 

Lard |j. 

M. Use cautiously in tubercular syphilis, lupus, 
and acne indurata. 

77. 5 lodo-chloride of mercury gr. iij. to gr. x. 

Lard | j. 

M. Use as above. 

78. IJ Red pi-ecipitate, finely powdered ) .. 

White precipitate ) 

Lard | j. 

M. Unguentum mercuriale co. Used in seba- 
ceous, squamous, ulcerous, tubercular, and 
papular eruptions. SUirtiii, 

79. 5 Iodine f ss. 

Glycerine 3 ij. 

Olive-oil I iiiss. 

Strong mercurial ointment 5 y* 

M. The liuamentum hydrarg. et iodini of Startin. 
Used in tubercular and cachectic affections. 

80. 5 Bichloride of mercury gr. iv. 

Dilute nitric acid 3 j- 

Dilute hydrocyanic acid 3 j. 

Glycerine 3 ij- 

Water 3 viij. 

M. Startin's noted Lotio hydrargyri bichloridi. 
Used in syphilitic eruptions, pityriasis, 
chloasma, etc. 

81. li Olive-oil 5 ij. 

Fresh lard | ij. 

Red precipitate 3 j. 

Oil bitter almonds gtt. x. 

Glycerine 3 j- 

M. Startin's lin. hydrarg. nitrico-oxydi. Used in 
pityriasis. 



FORMULABY. 279 

SULPHUR. 

82. IJ Iodide of Sulphur gr. x. to 3 j. 

Lard § j. 

M. . Use in acne. 

83. 5 Precipitated sulphur | 

Alcohol J ^^2J- 

M. Use in acne. Ilebra. 

84. 5 Hypochloride of sulphur 3 ij^' J // 

Subcarbonate of potash gr. x. 

Lard 3 j. 

01. Bitter almonds gtt. x. 

M. Use in acne. Wilson. 

85. IJ Sulphuret of potassium 3 ss. 

Lime-water | xvj. 

M. Use in pityiiasis, pustular and parasitic dis- 
eases. 

TAR. 

86. 5 Tar 1 

Alcohol f ^ 3J- 

M. Use chiefly in psoriasis. 

86. 5 Pyroligneous oil of juniper 3 j. to 5 j« 

Mutton suet 5 ^^ 

Lard 5 j. 

M. Use in eczema and psoriasis palnmris, etc. 

87. ? Tar 3j. . 

Camphor gr. x. 

Lard 3 x. 

M. Use in pruritus, in vesicular and papular di»- J^aume. 

eases. 

LEAD. 

88. 5 Acetate lead gr. xv. 

Dilute hydrocyanic acid Til xx. 

Alcohol 3 ss. 

Water, q. s. ad 3 vj. 

M. Use in impetigo. 

88. I^ Iodide of lead gr. xij. 

Chloroform IT^ xl. 

Glycerine 3 j. 

Lard f j. 

M. Use in eczema and psoriasis. Hdcher, 



280 FORMULARY. 

SILVER. 

89. ^ Chloride of silver gr. v. to gr. xv. 

Lard ^bs. 

White wax 3 ij« 

M. Use in psoriasis. 

90. 5 Nitrate of silver gr. ij. to gr. x. 

Water | j. 

M. Use in eczema and erytheuiata. 

BISMUTH. 

91. 5 Subnitrate bismuth 3 ij*] 

Bichloride of mercury gr. x. 

Spts. camphor 3 ss. 

Water, q. s. ad 5 ^XJ* 

M. Lotio bismuthi nitratis. Use in sebaceous, 

pustular, and vesicular diseases, and in 

pityriasis. Use diluted with from 1 to 3 

pai*ts water. Startin, 

PHOSPHORUS. 

92. 51 Phosphorated ether 3 j. 

Ceiate, free from water 3 v. 

M. Use in lupus, syphilitic tubercles, acne rosacea. Jiurgess, 

93. IJ Phosphorus gr. ij. to gr. v. 

Ether, q. s. to dissolve. 

Camphor gr. xx. 

Cerate ^ss. 

M. Use as above. 

ZINC. 

94. IJ Oxide of zinc 3 ij« 

Calamine powder 3 ij- 

Glycerine 3 ij • 

Rose water 3 viij. 

M. Use in eczema, generally where the surface 
is tender and red. 

CREASOTE. 

95. IJ Creasote 3uaa. 

Glycerine 3 iij* 

Water j vj. to 3 viij. 

M. Use in pityriasis. 

VARIOUS. 

9G. IJ Tr. nux vomica §88. 

Spirits camphor ) »« , •• 

Essence ciiraway ) 

Distilled water 3 vij. 

M. Use in chronic lichen simplex. Ndiffan. 



FORMULARY. 281 

97. R Bichloride of mercury gr. viij. 

Distilled water | iv. 

Sulphate zinc ) --^.. 

Acetate lead ) 

Alcohol 3 ij. 

M. Hardy's Lotion for ephelides. Use night 
and morning. 

98. 3 Mezereon bark ) -5 z * 

Horse-radish ) ^ ' 

Distilled vinegar, hot 5 "^j* 

M. Infuse for a week and sti*ain. Use in tinea 

decalvans. Wilson. 



99. 5 Persulphate iron 3 j- 

Tincture iodine ) ._^. 

Soap liniment f '^'^^J- 

M. Use in chilblains. 

100. 3 Bichloride of mercury g^*- j* 

Tincture benzoin 3 ij. 

Distilled water § vj. 

M. Virgin's milk. Use in acne. 

101. ? Cod-Uver oil ) .... 

Tincture cantharides ) 

M. Use in syphilitic alojxjcia. 

jAingatan Parker, 

102. 5 Cod-liver oil ? j. 

Solution ammonia 3 ss. 

Tincture cantharides $ ss. • 

Honey-water 3 ij. 

Essence rosemary 3 iv. 

M. Use in syphilitic alopecia. 

Langston Parker, 



103. 5 Balsam Peru 3 ij. 

Oil lavender gtt xij. 

Simple cerate | iiss. 

M. Use in loss of haii*. 

104. 51 Fowler's solution 3 j. 

Distilled water ? j. 

M. Use in lupus. 

Hooper, 



282 FORMULARY. 

105. IJ Subcarbonate soda 3 ij* 

Extract opium gr. x. 

Slaked lime 3 j. 

Lard 5 ij. ^ 

M. Use in prurigo. J>ieU. 

106. 5 ^^ Bitter almonds 3 ij. 

Cyanide potassium' gr. xij. 

Galen's cerate 3 ij. 

M. Use in itcking and prurigo. 

107. Ijl Cyanuret mercuiy P** "^j* 

Simple cerate | j. 

M. Use in syphilitic ulcers. 

108. 5 Chloride of lime §88. 

Oil sweet almonds 3 ij. 

Lard | iij. 

M. Use in papular itching. 

109. 5 Hyposulphite of soda 3 j. 

Glycerine § j. 

Water | iij. 

M. Use in pruritus vaginsB. 

1 10. IJ Biborate of soda 3 iss. 

Hydrocyanic acid, dilute 3 ss. 

Glycerine 3 iij^ 

Water | vi. 

M. Use in syphilitic palmar psoriasis. Startiu, 

111. 5 Ammonia chloride of mercury 3j. 

Olive oil ) - . 

Lardt [ **5J- 

Oil roses gtt. vj. 

Tincture tolu gtt xx, 

M. Use in pityriasis capitis. 

112. 5^ Liq. carbonis detergens §88. 

Glycerine | ss. 

Acid hydrocyanic, dilute 3 j« 

Water 5 x. 

M. Use in lepra vulgaris. 

113. 5 Citrine ointment | ss. 

Camphorated oil J 

Glycerins J ^ 

M. Use in lepra vulgaris. 



FORMULARY. 283 

MIXTURES. 

Chiefly those of use in more obstinate and chronic cases. 

MERCURIAL. 

1 14. 9 Bichloride of mercury g^« iV *^ i 

Dilute hydrochloric acid gtt. x. 

Water ? j. 

M. Take at one dose. 

1 15. 5 Hydrarg. bichloride ff^* y 

Iodide potassium 3 ij. 

Water f iij. 

M. Dose : A dessert-spoonful three times a day. 

Use in acne. £urge88, 

116. IJ Bichloride of mercury 3 j. 

Iodide potassium 3 vj . 

Comp. tincture iodine ^ 3 ij. 

Water q. s. ad § xvj. 

M. Startin^s mixt. hydrargyri iodidi. N.B. — 3 j. 

contains ^ gr. bichloride and gr. 3 of 

iodide. 

117. 5 Bichloride of mercury gr. i to -j^. 

Arsenious acid gr. gV ^ l^ff* 

Water | ss. 

M. For one dose. 

1 18. 5 Biniodide of mercury gr. iij. 

Iodide Potassium 3 i. to 3 ij« 

Alcohol 3 ii. 

Syr. ginger 3 iv. 

Water q. s. ad 3 iss. 

M. Dose : 30 drops three ti-mes a day. Puclie, 

1 19. 5 Biniodide of mercury gr. j. to gr. ij. 

Iodide of potassium § ss. 

Water § viij. 

M. Dose: a tablespoonful in a cup of ptisan, 

with the waters of Bareges and Louchon. Ilanfy, 

120. 5 Donovan's solution, or liq. arsenici et hy- 

drargyri iodidi. 
Dose : TTl 10 to 30. 3 j. contains gr. ^ of arseni- 
ous acid, gr. \ of peroxide of mercury, and 
about gr. } of iodine converted into hy- 
driodic acid. 



284 FORMULARY. 

121. IJ Bicyanide of mercury gr. ij. to x. 

Water 3 xvj. 

M. Dose : One tablespoonful ftight and morning. 

Uses — The above are used chiefly in secondary 
syphilis; the 3d, 5th, 6th, and 8th espe- 
cially in tubercular forms ; the 4th and 7th 
in ulcei'ation when it is of a sypliilitic na- 
ture ; and also in obstinate forms of acne. lAingston T^arker. 

ARSENICAL. 

122. 5 Wine of iron § j. 

Simple syrup 3 ss. 

Fowler's solution gtt. xlviij. 

Dist. water 3 vj. 

M. Dose : a tablespoonful twice or thrice a day. 
3 j. contains Tit 4 of ai*senical solution. 

123. ]J Fowler's solution Til Ixxx. 

Iodide potassium gr. xvj. 

Iodine !?*• iv. 

Orange-flower water 3 ij. 

M. Dose : a teaspoonful three times a day. Use 

in eczema. N^dii/au, 

124. IJ Cod-liver oil 5 ij. 

Yolk of egg Til j. 

Fowler's solution V\ Ixiv. 

Syrup 3 ij. 

Distilled water q. s. ad 3 iv. 

M. Dose : one teaspoonful three times a day. Wilson. 

1 25. IJ Bromide of iron 3 ss. 

Fowler's solution 3 j. 

Elder-flower water 3 iss. 

Orange-flower syrup ^ ss. 

M. Dose : a teaspoonful three times a day. Use 

in anaBmic subjects. Ndigan. 

12G. IJ Arseniate soda gr. j. to ij. 

Distilled water 3 viij. 

M. Dose : one tablespoonful daily ; then two, in 
conjunction with, alternately, alkaline and 
vapor baths, and tinct\ire cantharides night 
and morning, and the mineral waters of 



FORMULARY. 285 

St. Sauveur and Loueche. Use — beneficial 
in lichen, also in psoriaris and chronic 
eczema. Hardy, 

127. 9 Fowler's solution j .. 

Tincture cantharides J ^ 

M. Dose : ten drops twice a day, increased to fif- 
teen drops. Use in psoriasis especially. Hennett. 

128. 5 Solution chloride arsenic 3 j. 

Dilute hydrochloric acid 3 j. 

Tincture sesquichloride of iron 3 iss. to 3 iij. 

Water § viij. 

M. Dose : a sixth part three times a day. 

FERKUGINOUS. 

129. 5 Sulphate of magnesia § iij. 

Sulphate iron 3 ij. 

Dilute sulphuiic acid 3 ss. 

Infusion of quassia q. s. ad 3 xvj. 

M. Dose : 3 ij. to 3 ss. 

Use in acne, eczema, impetigo, and ulcerous 
affections. (An aperient tonic.) The mix- 
ture ferri acid of Startin, 

1 30. 5 Sulphate of magnesia 3 v. 

Syrup iodide of iron 3 j. 

Oil peppermint TTl x. 

Water, q. s. ad 3 xvj. 

M. Dose : 3 ij. to 3 ss. The mistura ferri iodide of Startin. 

1 31. 5 Citrate iron 3 j. 

Iodide of potassium gr. xviij. 

Tincture cantharides ) ., ^ .. 

Tincture cardamoms ) 

Water, q. s. ad 3 xvj. 

M. A sixth part thi'ee times a day. Use in ru- 

pia. ]vinniei\ 

VARIOUS. 

132. 5 Sulphate magnesia 3 V. 

Carbonate magnesia 3 ss. 

Tincture colchicum 3 j. 

Oil peppermint Tli x. 

Water 3 xvj. 

M. Dose : 3 ij. to 3 ss. Use in erythematous, 



2Sr> FORMULARY. 

papular, and acute forms of disease in 
loaded habits. 

133. IJ Sarsaparilla 3 xij. 

Water O xxiv. 

Boil for two liours, into which is suspended 
in a linen bag — 

Alum 3 iss. 

Calomel 3 ss. 

Oxysulphui-et of antimony 3 j. 

Liquorice 3 iss. 

Senna leaves , 3 ij. 

Aniseed 3 ss. 

Remove from the fii-e and allow it to infuse. 
Strain off sixteen pints. This is decoction 
No. 1. To make decoction No. 2, take 
the residue of No. 1. with Zitttnan. 

Sarsaparilla 3 vj. 

Water O xxviv. 

Orange peel \ 

Cinnamon >• fta 3 iij. 

Cardamoms ) 

Licjuorice 3 vj 

Infuse and strain sixteen pints. Use in ter- 
tiary syphilis. ZUi/nan, 

134. IJ Tincture guaiacum 3 j. 

Tincture aconite VI xx. 

Camphor mixture 3 vj. 

M. Dose : ? ss. three times a dav in chronic skin 
diseases. 

135. IJ Tuq)entine rectified 3 ss. to 3 isR- 

Creasote l^i iij. 

Spiiits of rosemary TTl xl. 

Water, q. s. ad 3 iv. 

M. Dose : Two t«isj)ooufuls every three or four 

hours. Use in purpura. 2?M</r/. 

13i». IJ Borax 3j. 

Bitartrate j>otassa r ss. 

White sugar 3 ij* 

Water ? xvj. 

M. DoJ*e : Two tablosptX)nfuls everj* six hours. 

Use in erythema nodosum. Xetigan, 



FORMULARY. 287 

I 

137. 5 Almond oil § ss. 

Olive oil § ij. 

Iodine gr. i. 

M. Dose : A third part three times a day. Use 

in scrofulous eruptions. Duncan. 



I 



138. 5 Tincture guaiacum compound 3 j- 

Tincture serpentaria 3 ss. 

Mucilage TT^xx. 

Decoction mezereon 3 viiss. 

Decoction dulcamara 3 j. 

M. To be taken three times a day for psoriasis 

guttata. Neligan, 



• PHOSPHOROUS. 



• 



1 39. 5 Phosphorus gr- x. 

Almond oil 5 J* 

M. Dose : Five or ten drops in emulsion. 



# 



140. 5 Phosphorus 4 parts. 

Ether 100 parts. 

M. Dose : Five to ten drops. Use in acne esi>e- 
cially. 

STRYCHNINE. 

141. 9 Strychnine gr. j. 

Dilute phosphoric acid 3 iij- 

Tincture orange peel § ss. 

Infusion cloves 3 xj. 

M. Dose: Half an ounce three times a day. 

Use in prurigo and lichen. Fraaer. 

PILI.S, ETC. 

142. 5 lodo-chloride of mercury gr. iv. 

Gum arabic gr. xv. 

Bread crumb 3 iiss. 

Orange-flower water q. s. 

Make 100 pills. Dose : One to three daily. 

Use in acne. jRocJianf, 

143. 9 Biniodide of mercury gr. j. to ij. 

Extract gentian ^ 3ij. 

Make 12 pills. One pill twice a day. 



• 



288 FORMULARY. 

144. IJ Protoiodide of mercury gr. xvj. 

Extract lettuce 3 ss. 

Make 40 pills. Dose : One to four daily. 
Use in syphilodermata. 

1 15. "^ Bicyanide of mercury gr. xxiv. 

Muriate anmionia 5 iij- 

Guaiacum § HJ* 

Exti'act aconite 3 iij« 

Oil of anise gr. xxiv. 

Make 400 pills. Dose : One pill three times 
a day. Each pill contains ^ gr. of the 

bicyanide. Use in syphilis. Langstan JParker, 

ARSENICAL. 

1 46. ^ Arseniate soda gi** ij • 

Water, sufficient to dissolve. 

Guaiacum powder 3 ss. 

Oxysulphuret of mercury 3j. 

Mucilage sufficient to make 24 pills. 
Dose : One, two, or thi'ee times a day. Use 
in chronic skin diseases. 



147. 5 Arseniate soda g*** ij* 

Extract of hops gr. xx. 

Sulphate iron gr. xx. 

Exti'act nux vomica ^* Uj* 

M. Make 24 pills. One three times a day. 
Use in chronic eczema and lepra. 

148. IJ Levigated arsenious acid gr» v. 

Powdered acacia 3 ss. 

Cinnamon powder. '. . 3 iij» 

Extract jalap 3 ij* 

Glyc<3iine enough to make 100 pills. 
Stai-tin's Pil. Arsenicalus composita. Dose: 

One or two a day. Each pill contains ^ 

gr. arsenious acid. 



... 



IVilsan, 



149. 5 Arsenite iron g*** ^y* 

Extract hops * . . . . 3 j» 

Powdered marshmallow 3 ss. 

Orange-flower water enough to make 48 pills. 
Dose : One to two daily. Use in chronic lepra, 

psoriasis, and lupus. UnM. 



FORMULARY. 289 

180. 9 Iodide of arsenic gr. ij. 

Manna gr. xl. 

Mucilage q. s. 

Make 20 pills. Dose : One pill three times a 
day. Use in lepra vulgaris. 

VARIiE. 

151. If, Exti*act of aconite l-a 

V aa gr. xv. 

Extract of dandelion ) 

Make 40 pills. Dose : Two pills night and 
morning. Use in prurigo, in conjunction 
with starch baths and arseniate of iron. Cazenave. 

151. "^ Extract mix vomica g^^* iij- 

Inspissated ox-gall gr* vj. 

Extract dandelion gr. xxiv. 

Myrrh gr. xxiv. 

Make 24 pills. Dose : One pill three time.s 

a day.. Use in prurigo. J^digan. 

152. 9 Phosphorus gr. iij. to gr. xx. 

Almond oil gtt. x. to Ix. 

Powdered acacia q. s. 

Make 12 pills. Dose : One twice a day. 
Use in lupus and syphilitic tubercular 
• disease. I^urgesB, 

153. IJ Sublimed sulphur | ij. 

Bitartrate potassa 3 j. 

Powdered rhubarb 3 ij» 

Powdered guaiacum 3 j. 

Honey ft j. 

M. Dcse : Two tablespooufuls three times a day. 
Use in chronic skin disease. 

REMEDIES FOR PARASITIC DISEASES. 

Those agents which are destructive to parasites are termed Parasiticides. 

A. 

REMEDIES OF SPECIAL USE IN ANIMAL PARASITIC DISEASES VIZ., SCABIES 

AND PRURIGO. 

154. 5 Sulphuret potassium 3 vj. 

White soap fbij. 

Olive oil O ij. 

Oil thyme 3 ij. 

M. Use in scabies and prurigo. AutJior, 

19 



290 FORMrLARY. 

155. 5 OUveoil 5 ij. 

Sulphate of potash 3 xv. 

Sulphate of soda 3 xv. 

Precipitated sulphur 3 x. 

M. Use in scabies. MoUard. 

156. 5 Sulphur ) 

Tar \ ^^ ?^J- 

Soft soap ) 

Lard \ ^^ 3xvj. 

Chalk |iv. 

M. Use in scabies. JSTebra. 

156. 5 Lard | ij. 

Sulphur 3 V. 

Carbonate potash ) 

Water \ ^ ^y. 

M. Use in scabies. ITardif. 

157. IJ Ammonio-chloride mercury ointment 3J. 

Musk g*"' \i- 

Oil lavender gtt. ij. 

Almond oil 3 j« 

M. Use in prurigo and scabies. WilMon. 

158. IJ Iodide sulphur J 

Iodide potassium J 

Water 3 xxxii. 

M. Use in scabies. Cazeruwe. 

159. 5 Olive oil 5 as. 

I-Ard 3 ss. 

Powdered stavesacre 3 ij- 

M. Use in prurigo pedicularis. 

1 60. IJ Chamomile powder ^ 

I^rd C &a f j. 

Olive oil ) 

M. Use in scabies. Said to cure in throe frictions. StKsin^ 

161. IJ Sublimed sulphur 3 ss. 

Ammonia-chloride of mercuiy gr. x. 

Sulphuret of mercury with sulphur gr. x. 

Mix, and add 



FORMULABY. 291 

Olive oil 3 ij. 

Greasote gtt. iv. 

Fresh lard 3 ij. 

M. Use in scabies. XJng. sulpburis co. of Startin, 

162. Iodide of potassium ointment is very effica- 

cious in scabies. 

163. 9 Sulphur ointment 3 ij. 

Oil chamomile gtt. xx. 

M. Use in scabies Wilson. 

N.B. — For prurigo pedicularis the ordi- 
nary white precipitate ointment of the Phar- 
macopoeia is as good as ady. 

B. 

REMEDIES FOR VEGETABLE PARASITIC DISEASES. 

1. Vesicating parasiticides (applied, when it is desired, at the outset, to 

destroy the fungus in an early stage of disease.) 

164. 5 Bichloride of mercury 3ij. 

Dilute hydrochloric acid 3 »». 

Alcohol 3 iv. 

M. Use in early stages of tinea tonsurans. 

165. IJ Bichloride of mercury gr. x. to xx. 

Elder-flower ointment 3 j. 

M. Use in early stages of favus and tinea tonsu- 
rans. 

166. 5 Tincture iodine comp 3 j. 

Iodine gr. x. 

Iodide potassium gr. xv. 

M. Use in chronic stages of parasitic disease. 

167. ]J Carbolic acid 3 j. 

Glycerine ^aa. 

M. 

168. 5 Powdered cantharides 5 U • 

Concentrated pyro-acetic acid 5 ^^j* 

Tannic acid | j. 

M. Macerate for a week and strain. Use in 

tinea decalvans. Startin, 



292 FORMULARY. 

2. Milder parasiticides (for ordinary use). 

169. IJ Sulphuret lead potassium 3 iij* 

Soft soap ' I j. 

Lime-water 3 viij. 

Alcohol I ij. 

M. Use in scabies and ringworms. Cheen, 

170. IJ Hyposulphite soda 3 iij. 

Dilute sulphurous acid | ss. 

Water q. 8. ad 5 ^cvj. 

M. Use in all forms of parasitic disease. JSlarUn. 

171. IJ Bichloiide mercury gr. ij. to iv. 

Alcohol 3 iv. 

Muriate ammonia 3 ss. 

Rose-water q. s. ad 5 ^j. 

M. Use in scabies, prurigo, and tinea versicolor. 

172. IJ Precipitated sulphur 3 ij- 

Spirits camphor 3 ss. 

Glycerine | ss. 

Bisulphuret mercury 3 ss. 

Powdered starch 3 ij. 

Water.. ad | x\j. 

M. Use in ringworm of the scalp. Startin, 

173. 5 Carbolic acid 3 ij. 

Glycerine 5 j« 

Rose-water q. s. ad § viij. 

M. Use especially in ringworm of the surface. 

174. 9 Borax 3 ij. 

Glycerine 3j. 

Lard |j. 

M. Use in ringworm of the surface. 

1 75. IJ Yellow sulphuret mercury 3 ss. 

Oil almonds 

Glycerine 

Lard §ij. 

M. Make unguentum phyticidum. Use in tinea. Sazin. 



[ aa 3 ij. 



176. 5 Pyroligneous oil of juniper 3 ij. to 3 iv. 

Lard | jjss. 

M. Use in tinea. 



FORMULARY. 293 

177. IJ Soft soap 3ij. 

Pyroligneous oil juniper \ 

Alcohol * . . V && 5 88. 

Glycerine ) 

M. Use in tinea. JSegbie, 

178. 9 Hyposulphite soda 3 iv. 

Glycerine 3 ij. 

Water q. s. ad 3 vj. 

M. Use in tinea versicolor. 

180. IJ Citrine ointment 3 iv. 

Sulphur 3 ij. 

Creasote gtt. x. 

Lard 3J- ^ 3 U- 

M. Use in ordinary lingworm and tinea sycosis. 

181. IJ White precipitate g^* XJ. 

Red precipitate, powdered g^- XJ. 

Lard : IJ. 

M. Use in all forms of ringworm. Startin. 



\ 



182. 5 Sulphur. ^ 

r ^^ 3 J' 

Tar ointment , 

Glycerine 3 iv. 

Strong mercurial ointment 3 iij. 

M Use same. 

183. IJ Carbonate copper 3 ij. 

Lard §j. 

M Use generally in parasitic diseases, especially 

in tinea sycosis. Devergie. 

DEPILATORIES. 

184. IJ Fresh lime 3 ij. 

Sal soda 3 iij. 

Simple cerate 3 ij. 

Hayer, 

185. 5 Lime 5 iss. 

Sulphuret arsenic 3 j. 

Starch 3 x. 

SOOTHING APPLICATIONS. 

186. IJ Oxide zinc ointment benzoated | ij. 

Glycerine 3 iij. 

Spirits rosemary gtt. x v. 



294 FORMULABT. 

187. IJ Laudanum ) " % ' tn T " 

Goulaiyl^s extract of lead J ' •'* ^' 

Mder ointment | ij. 

SPECIAL STIMULANTS OF THE SCALP. 

188. IJ Glycerine 3 iij. 

Lime-water liniment | iv. 

Tincture cantharides 3 iij. 

M. 

189. IJ Distilled vinegar 5 ^^^^s. 

Tincture cantharides 3vi.to 3 viij. 

Rose-water 5 iiiss. 

M. 

190. I^ Strang ammonia liniment. ^ ss. 

Castor oil ^sa. 

Spirits turpentine purified | ss. 

White precipitate gr. xv. 

M. Brush into the scalp with a hard nail-brush 
until irritation is set up. 



MINERAL WATERS IN SKIN DISEASES. 



The following is a list of the principal " waters " of use in the treatment 
of skin diseases, especially those of chronic character, for which I am in- 
debted to Dr. Althaus : — 

A. Foreign : — 

1 TTTna ) 

' 5, , / > For eczema and prurigo. 

2. Wiesbaden ) Ulcers and chronic skin diseases, 

Bourbonne le^s Bains f with abdominal plethora. 

• p"n^ ^ f Scrofulous skin diseases. 

4. Rehme ) Eczema in the early stages, and pity- 

Nauheim f riasis. 

5. Kreuznach ) Lupus, sycosis, lichen, ichthyosis, 

Krankenheil ) scrofulous ulcers. 

6. Leuk (Lou^che) I ^""skbi^l^es^''' "^"^ *" ''^'^''''' 

7. Wildbad ^ 

Gastein I Prurigo, psoriasis, and lichen, where 

Pfaeffei-s ( there is nervous debility. 

Teplitz J 

8. Spa ^ 

Schwalbach ! Skin diseases connected with or ow- 

Pyrmont [ ing to ansemia. 

Franzensbad 

9. Aix-la-Chapelle 

Baden (near Vienna) 

Baden (in Switzerland) 

Aix-les-Bains 

Bagnei'es de Luchou 

Bareges 

St. Sau veur 

Eaux Bonnes 

Nenndorf 

SandeQord (Norway) J 



All sulphurous waters, useful in 
>• acne, pityriasis, psoriasis, pru- 
rigo, sycosis. 



B. English Waters :— 

1. Sulphurous. — Harrogate, Moffat, Cheltenham (sulphur spring). 

2. Saline. — Cheltenham, Buxton, Bath, Scarborough, Leamington (New 

and Old Bath). 

3. CludyheaU, — Tunbridge, Cheltenham (chalybeate), Brighton. 



296 MINERAL WATERS IN SKIN DISEASES. 

4. J^ronw-iodine, — Purton, in North Wilts, temperature 58^** F., useful 
in strumous subjects ; and the Woodhall Spa in Linco]nshii*e. 

*' It is probably unknown to many of our readers that midway between 
Boston and Lincoln there exists one of the most valuable and remarkable 
spas to be found, not merely in Great Britain, but in Europe — namely, the 
Woodhall bromo-iodine spa. It is one of the very few spas in this country 
which contain in any medicinal quantity those potent and most beneficial 
agents, bromine and iodine. Amongst the Continental mineral waters, it 
most closely resembles that of the celebrated Kreuznach Spa, to which in- 
valids of a certain class resort from nearly all parts of the world. It dif- 
fers from and is superior to the waters of that spa in the very much larger 
quantities of bromine and iodine present in the former, and which are 
stated to be some three or four times as great. 

" The water of the Woodhall Spa has been more than once very carefully 
tested, and, as there can be no doubt of the substantial accuracy of the analy- 
ses made, we have thought it unnecessary to make a full quantitative ex- 
amination ; we have, however, verified the presence of bromine and iodine 
in large amounts. The late Mr. West, who very carefully tested this water, 
stated that the presence of iodine might be detected with the starch and 
sulphuric acid test, without the water undergoing any preliminary evapora- 
tion. 

" In the bromo-iodine water of the Woodhall Spa we have therefore a 
very powerful remedial agent, especially valuable in the very large class of 
cases of scrofula and chronic rheumatism, tumors, etc.*" — TJie Jjancet^ Feb. 
22, 1865. And I may add tertiary syphilis. The water of the spa at Wood- 
hall contains a propoi-tion of 5^ grains of iodine to 10 gallons; and 20^ 
grains of bromine in 10 quarts. 

I should think tliat the Woodhall Spa may turn out to be a valuable 
remedy in skin diseases. 



GLOSSARIAL INDEX. 



PAGE 

AcHOR (a;(U)p scurf) is a term at one time applied to a small acumi- 
nated pustule of the scalp, containing straw-colored pus, and 
succeeded by a thin brown or yellowish scab. The word has now 
fallen quite into disuse 11 

Achorion. The generic name given to the vegetable parasite in tinea 

favosa. It is probably a form of penicillium glaucum 215 

Acarus. A genus of minute insects belonging to the acai*ides in the 
division of arachnides. The following two varieties arc found 
on man : — 

(1) Acarus autumnalis — the harvest bug 190 

(2) Acarus scabiei, or itch insect 198 

The so-called acarus Stockholmii is probably a species of tick, 

and the acarus folliculorum is now termed steatozoon foUicu- 

lorum 254 

Acarus scabiei (difference of sex) 198 

'' habits of ]9G 

" selective seat of 19r 

" male 198; 

" female 202: 

Acne should really be acme, from the Greek oKfjiri, Dr. Greenhill 
believes that in the word ** acne " the n is by mistake placed for 
m, and that this eiTor arose with Aetius. By acne is meant an 
intlanimation of the sebaceous follicles due to retei^tion of sebace- 
ous matter, and this was thought to occur at the acme of the 

system 256« 

Acne, general description of, &c 257 

" syphilitic 149 

Acrochordon (aicpov extreme, and x^P^ * string). A wart which has 
a pedicle or a thin neck by which it hangs from the skin : a 

' pedunculated wart 1 70^ 

Acrodynia (aKpov the extremity, and oSvvrj pain). The name given 
by Alibert to an epidemic erythema as occurring in Paris some 
years since, in which there were severe pains of rheumatic char- 
acter about the wrists and ankles 48 

Acute Specific Diseases (eruptions of) 32, 42 

Addison's keloid 179 



298 GL088ARIAL INDEX. 

PAOI 

Age (influence of) 126 

Agiius, an adjective signifying inflamed, derived from ayplos angry, 

fierce, etc. See Lichen Agrius 79 

Aleppo evil 110 

Alopecia signifies baldness — derived from dA<o7n/f . a fox, in whom the 

hair falls out in mangy places 259 

Alopecia areata 224 

" syphilitic 153 

Allosteatodes (oXAos other, orcap fat, altered sebaceous secretion .... 253 
Alphos {aXfjios white), a term applied to lepra vulgaris because of its 

abundant white scales 1 23 

Alphous diseases (lepra vulgaris) 123 

Anaesthetic leprosy 159 

Angeiectasis (ayyctov a vessel, eKToo-ts extension), a term applied to 

hypertrophy of the vessels of the skin, or nievoid growths 186 

Angeioleucitis (ayyctoi' a vessel, Acvkos white) itis signifying inflam- 
mation), inflammation of the lymphatics. 
Anidrosis (a not, iS/uoxris jKjrspii'ation), deficiency or even absence of 

perspiiution 249 

Anomalous exanthem, a term applied to those rosy rashes which are 

like measles and scarlatina. False measles, rubella 42 

Anthrax (avOpa^ a burning coal), a term applied to carbuncle, from 
its dark coal-like appearance. It is also thought that the word 
carbuncle was used to designate the disease from the supposed 
resemblance of the inflammatory swelling to the stone carbuncle 101 
Area, a bald spot (from areo to be dried up). It has the same sig- 
nificance as alopecia. The ordinary bald s|K>ts on the head are 

called alopecia areata 225 

Amy itch 203 

Ai-senical remedies, 8ee Formulary 284 

" caustics, nee Formulary 284 

Ast-eatodes (a not, ariap fat), deficient secretion of sebaceous matter 253 
Atrophia (a not, rpo^rj nourishment), deficient nourishment, atrophy. 

Bacchia, a synonym of acne rosacea (from Bacchus, the god of wine) ; 
it being su])posed that the too free use of spirits was the cause 

of the disease 257 

Bakers' itch 81 

Baldness 259 

Baras, an Arabian designation for leprosy 160 

Barbadoes leg (bucnemia tropica, or elephantiasis Arabum), hyper- 
trophy of the fibrous tissues of the legs, commences with inflam- 
mation of the lymphatics 180 



OL088A.RIAL INDEX. 299 

FAOE 

Baths, see Forhulary 269 

Berat, one of the ancient terms used to designate the true leprosy ; it 

signifies "bright spot." Bei'at lebena was the bright white 

leprosy, or the luce of the Greeks, and berat cecha the dark 

leprosy, or the melas of the Greeks. 

Biesiadeoki^s observations on cell changes 15, 70 

Biskra bouton 109 

Blebs 9 

Boak, the Hebrew term for the lepra vulgaris, or alphos of 

Celsus • 

Boils 100 

Bots 191 

Bouton d'Alep 110 

Bricklayer's itch 81 

Bromidrosis (jSpcu/tos a stench ; i3/>ci>9 sweat), fetid perspiration. 
Bucnemia (fiov, a Greek augmentative, ocny/ii; the leg), the same as 

Barbadoes leg. Literally, as Hoblyn has it, bulky or tumid leg 180 

Bucnemia tropica 180 

Bug 190 

Bulla, from the Latin hdla^ a bubble. It is the term applied to 

blisters or large vesicles, as seen in herpes and pemphigus . 9 

Bullous diseases 112 

" " of syphilitic nature 114, 119, 187 

Cacochymia (kcuco9 bad, and ^v/aos juice), literally badness of juices. 
It is a term applied to any disease of the skin consequent upon 
alteration of the fluids of the body. 

Cacotrophia (kok^ bad, and Tpo<l>r] food), ill nourishment. 

Calvities, from cdtvus bald, a term generally signifying the baldness 

of old age 29 

Camp measles 207 

Cancer, Latin for a crab 29, 136 

Cancroid, cancer, and ctSo9 likeness, is the term a])plied to diseases 
like cancer, or semi-malignant affections like kelis. 

Canities {camis hoary), whiteness of the hair. 

Catarrhal inflammation 64 

Carate (from the Portuguese cards, complexion), a pigment disease 
(deficiency) seen in New Granada. 

Carbuncle, differently derived by authors, from carbo charcoal, be- 
cause of the black slough, or carbuncle, because of the red and 
fiery nature of the disease itself 101 

Carcinoma (KapKivwfia = KopKivos, cancer). 

Causes, general summary of 16 

" Hebra on 17 



300 GLOSSARIAL INDEX. 

PAOI 

Causes, Wilson on 17 

Caustics. 

Chalazion (xoAo^a hail or sleet). It is the term sometimes applied to 
the little sebaceous cysts found in the eyelids, and which look 
like a hail-stone. 
Cheloid (x^A.17 a crab's claw, and €^809 likeness), the disease usually 
called keloid, which consists of an indurated mass putting forth 
processes at its edge that resemble a crab's claw. See Keloid. 

Cliigoe 191 

Chionyphe Carteii 230 

Chloasma (xA-oufo) to be pale green), generally applied to the brown- 
ish stain of pityriasis (or tinea) versicolor, one of the ring- 
worms, but used by Hebra to signify pigmentary discoloration. . 227 
Chromatogenous (;(p(i)fia, )(pwfjLaToq color, ycWaco to produce), a term 
applied to the group of diseases in which the color of the skin 

is changed 244 

Chromidrosis (xp^/xa and tSpoais sweating), colored sweating 250 

Cicatrices 13 

Cimex lectularius, or bed bug 190 

Cingulum, the Latin for a girdle, and applied to herpes zoster or 
shingles. 

Classification. See Summary 21, 23 

" « Willan's 21 

Clavus (a nail), a term signifying a corn or callosity 170 

Cnidosis (kviSoktis an itching, caused by tlie nettle or icvi^), the term 
used by Alibert to designate nettle-rash. 

Cochin-China ulcer Ill 

Color, alterations of, in disease 244 

Comedones {comedo a glutton), the small sebaceous plugs or concre- 
tions that form in acne ; they are also called grubs 254 

Condylomata 171 

Contagious impetigo 94 

Corns 170 

Couperose, the French for cojyperas. Goutte roaey signifying acne, 

in which the color is reddish. 
Cow-pox, a synonym of vaccinia. 

Crusts 13 

Crusta lactea, literally milk crust. Tliis is a term that is generally 
applied to an impetiginous eczema in children, in which the 
crusting is free and light-colored ; but it has been made to in- 
clude many different affections, and has no definite signification. 
See Eczema. 
Cyanoderma (xvavcos^ blue, Sipfia skin), a blue discoloration of the 
skin. See Ciiromidkosis. 



GL088ARTAL INDEX. 301 

PAQB 

Cyanopathia (icvavco? blue, trdOo^ disease), the blue disease^ or 
cyanosis. 

Cysts of perspiratory glands 251 

" sebaceous glands 2«54 

Dandriff, or Dandiniff, signifies scurfiness, pityriasis of the scalp.. . 190 

Darti*e (Sopros flayed), a term applied by the French to the group 
of diseases including eczema, lepra vulgaris, lichen, and pity- 
riasis. These are supposed to depend upon a '^ dartrous diathe- 
sis." The word dartre is equivalent to tetter. 

Dartrous diathesis 69 

Demodex folliculorum (Si/fios fat, Soicvw, Srjiofiaiy to bite (Hoblyn). 
The term given by Owen to the insect found in the sebaceous 
matter ; called by Wilson steatozoon folliculorum 254 

Delhi Boil 108 

Dengue, or Dandy fever 41 

Depilatory (de from, piliL8 a hair), a remedy which causes the hair 
to fall off; it is usually made up of quicklime, subcarbonate of 
potash, and sulphuret of antimony. See Formulary 293 

Dermatitis (8cp/ia skin, and itis signifying inflammation), inflam- 
mation of the skin. 

Dermatalgia [Sipfia skin, and aXyo9 pain), neuralgia of the skin. 

Dermatolysis (3c/9/ia skin, and Xvo-is looseness), of the skin when it 

hangs in folds 184 

Dermatology (Scp/xa skin, and Xoyos a discourse) ; that branch of 
science wliich concerns the physiology and pathology of the 
skin. 

Dermatophyton {Sipfia skin, (f>vTov a plant, a vegetable parasite). 

The diseases in which these occur are called dermatophytic .... 207 

Dermatophytic diseases 207 

Dermatospasmus, means spasms of the skin. 

Dermatopathia, diseases of the skin in general. 

Dermatosis is used in the same way to designate diseases of the skin 
as a whole. 

Dermatozoa (Bipfia skin, ^Qtov an animal), animal parasites 191 

Dermic means relating to the skin ; Dermoid, skin-like. 

Diagnosis (Siayj^oMrts, a distinguishing), the ai-t of distinguishing dis- 
eases. 

Diagnosis of skin diseases (generally) 25 

" indications from mode of onset 26 

" temperament of patient 26 

" duration of disease 26 

" recurrence 26 

** occupation of attacked 26 



302 OLOSSABIAL IND^X. 

PAOI 

Diagnosis, age of pdllent 26 

" " seat of disease 26 

Diagnostic features of eruptions 27 

** " of syphilitic eruptions 143 

Diathesis (Stapedis a placing in order, a disposition), the general 
term for certain constitutional tendencies^ such as the rheu- 
matic, scrofulous, hsemorrhagic. 

Discolorations, or maculse, varieties of 6 

Dracunculus (deriv. of draco, a dragon), the Guinea- worm 192 

Dyscliroma (8v<rxpota), discoloration of the skin. 

Dyscrasis (Bva-Kpaaia bad state of body), a faulty state of the fluids 
of the blood. 

EccHYMOsis (cKx^fuiKTis), exti*avasation of blood. 

Ecphyma (lic<^v/iia), a pimply eru])tion. Mason Good applied the term 
to corns, warts, and the like. 

Ecthyma (ck^fia a pustule), a variety of pustular disease 97, 100, 155 

Ectrotic (c*cTpa>Ttxos abortive), a term applied to remedies that arrest 
the development of disease — make it to abort — as the nitrate of 
silver in small-pox pustulation, or erysipelas. 

flczema (cic^c/xa, from ck^civ to boil over), a variety of cutaneous dis- 
ease of vesicular nature 64, 78 

Eczema. Wilson'*8 views 69 

" Hardy's " 69 

" Hebra's view 68 

" Diagnosis 71, 75 

'' Ti-eatment 75, 78 

Elementary lesions, the ty{>e8 of form assumed by skin diseases 6 

Elephantiasis (cAc</>a$ an elephant). Tliis designation is applied to 
two diifei-ent diseases in which the skin is swollen and indurated 
like an elephants skin. The one is elephantiasis Gnecorum or 
true leprosy (p. 157), the other elephantiasis Arabum (Barba- 
does leg), or more generally now known as bucuemia tropica, or 
spargosis 180 

Ephelis (cTTi upon, eXea>9 the sun), sunburn or freckles 245 

Ephidrosis (c<^'6p<iKns slight perspiration), moderate sweating. 

Epidermophyton (cri^cp/iis epidermis, ^vrov a plant), a fungus attack- 
ing the epidermic cells. 

Epinyctis (c^l upon, W( the night), a pustule painful at night. The 
term was applied by Sauvages to ecthyma. 

Epiphyta (ciri upon, if>vTov a plant, epiphytes), fungi found on tlie sur- 
face 207 

Epithelioma, epithelial cancer 28, 136 



0L0S8ABIAL INDEX. 303 

FAGB 

Epizoa (cttI upon, f^wov an animal), animal parasites living upon the 

surface, such as acari, lice, <fec 190 

Equinia (equus the horse), the equine disease. 

Erysipelas (ipvOpo^ red, ?reXXa skin), a peculiar kind of skin inflam- 
mation dependent on a special poison 37 

Erythema (ipvOrjfui redness), simple redness of the skin 44 

" an elementary lesion 7 

Erythemata, diagnostic features of 27 

Erythematous diseases 44 

Esthiomenon (from co-0ta> to eat), eating ; an ulcerating or eating out 
sore ; generally applied to lupus in olden time. 

Etiology of skin diseases 14 

Exanthem (iidvOrffjua a breaking out). A term api)lied to febrile dis- 
eases which are accompanied by erythematous eruptions. 

Exanthem, syphilitic 145 

Exormia (€$opfirj a going or breaking out). This is an old appella- 
tion of ecthyma, probably. 

Farcy {from farcio to stuff). ' The disease is a variety of equinia or 

glandei*s 40 

Farcy and glanders 40 

Favus (a honeycomb, one of the parasitic diseases in which the fun- 
gus grows up into mass like honeycomb; it is properly called 

tinea favosa 214 

Ferruginous mixtures, see FoRMULiE. 

Fibroma (Jibra a fibre), the disease in which tubercles formed by 
hypertrophy of the white fibrous tissue of the skin occurs. This 

is often called fibroma molluscum 183 

Filaria medinensis, the guinea-worm 192 

Fish-skin disease — i. <?., ichthyosis 188 

Framboesia or yaws, a disease seen in hot climates, in which tuber- 
cles like raspberries appear ; hence the derivation, framboise a 

raspberry 42 

Flannel, its action as an initant 18 

Freckles 245 

Frequency, relative, of skin diseases 20 

Fungi, parasitic, detection of, structure, <fec 208 

" of favus 213 

** tinea tonsurans 215 

" tinea circinata 220 

" tinea sycosis 223 

" tinea versicolor (chloasma) 227 

*' decalvans 224 

Fungus foot of India, Madura foot or podelkoma, or ulcus grave. A 



304 OL088ARIAL INDEX. 

PAOE 

disease of the foot and hand, due to the presence and develop- 
ment of a fungus allied to a mucor, and named Chionyphe Car- 

teri 228 

Furfuraceous (from furfur, bran), bi*anny, scaliness. 

Furunculus (a boil), supposed to be derived from fur, a thief 100 

Furuncular affections 100 

Qale, the French for itch. 

Qelatio (from gdare, to freeze), frost-bite. 

Gown-red, tooth rash or strophulus. 

Gi-ando (a hailstone). See C/HALAZION, a small sebaceous cyst of the 
eyelid, like a hailstone. 

Grocer's itch 81 

Grutum, the term signifying grit, and meant to express the millet- 
seed or I'rit-like appearance of enlargements of the sebaceous 
glands ot the face. 

Glands, diseases of — 

** sebaceous 252 

" pei-spiratory 248 

Guinea-worm disease 192 

Gum-red, a synonym of strophulus. 

Gutta rosacea, literally a rosy drop ; in French, goutle rose y Latin, 
gutta, a drop ; a term applied to acne rosacea. 

HiEMATODVSCRASiA (at^ia, atfiaTos, blood ; hxHTKpacria. bad temi>erament), 

an unwholesome condition of blood. 
Hsematoma (at/iaroui to make bloody), a sanguineous cyst. 

Ha)midrosis (aifia blood ; l^pwcri^ sweating), blood pei*K])iration. 

Hair, diseases of 259 

Harvest-bug, the acarus autiminalis. 

Herpes (Ipirui or tpirtiv to creej)), originally signifying a creeping or 

spreading eru])tion, and applied to ulcemting diseases, such as 

lupus. Now it is limited to an eruption of vesicles seated upon 

a red base 112 

Herpes, its varieties, «tc 113, 117 

** syphilitic 114, IIG 

Heterologous (Ircpos other, and Xoyos an account), a term applied to 

n(iw formations dilferiug in nature from those which already 

exist normally in the body, such as cancer, tubercle. 
Heteroplasia (TrXao-ts formation). It luis the same significatiim as 

tlie last word — literally abnonnal sti^ucture. 
Hidroa and Hidrosis (i^/>a>s sweat, rSp<oo-is sweating): the fii*8t is a 

term for miliaria, the second for excessive sweating 248 

Hives, the popular name for chicken-pox. 



OLOHSARIAL INDEX. 



Sfdedlum (ft diraimitive of horJevm barley), a. eLy or inllameil Mei- 
bomjaa glimt] in the eyelid, so named fi-om its reseinblftnce to u 

hiirley-carn 

[om-pock, the niodilied form of araall-pox, in wliich tlie fan oi- 
gpota abort, and dry up into hardiah jiapulutions. 

Hydrargyria (Mpopyupos mercury), the erythema produced by mer- 
cury applied locally; it is Hometimea called eaxma mei-i^iricUe. 

Hydroa (uSuip water) is the same as hidrna, 

Hydro-adeoitis {^nap and nilemlig, gUud iiiftummation), ijifl animation 
of the swwit glandti 

Bj^rtemia iimip, over or above, and aXfta., blood), eiwss of biood; 
congnstive; of an active kind. 

HxperiBstbesia (aurAjo-is Bensation), exalted sensibility of tt port. .... 
(yperidrosis (tw«p in escesa, and 'SpciKTii 8we»tiug), excessive B%peat- 

2BI| 

[^perpltuift (vTTc/j above, and irXairtT conformation), excessive forma- 
tion of tissue. 

Bypertrophy {vvip and r/m^^, nutrition), on excess over and above 
tbe standard nourishment of a part, by which change of size and 
form are Itrought about — iu a word, excessive growth. 

HypertropUia vcimrum - 

Hypertrophic and atrophic atTections 

m Iatbalbptic meth,od (Earpos surgeon, liAii'i^ to anoint), the mode of 

^^^H medication by friction of medicines. 

^^^■^tliyoais (ix^ a tish), the fiah-Bkin (Useaae, from the reHe-nibliince 

^^^Hp of the scales of the disease to those of a fish 

^^^^Tidrosis, same as Hydrosia, 

Impetigo (im/ieto to attack, or tmpetire to infeat). It has been ap- 
plied to very many different diseases in itaat times. It in now 

used as designating one of the puutular diseases. 91, 97a 

npetigo contagiosa ?^f 

mportance of studying skin diseases 

tflommation, cutaneous 

Entertrigo (tfiier between, (ero to chafe), ucliafe gall or fret. Tlie excori- 
ated surface produced by the friction of two surfaces of the skin. 

Introduction t] 

inthos (from tofScK the i-oot of the hair, allied to itSfio to bloom, 
nrding to some, from loi' violet, and a><6os a flower). It was 
applied to the acne of the face that appears at puberty when the 
hair of the beard is forming. 
I, preparations of, «m Foruulabv. 
a. leprosy 



il,VI, ISIJEX. 



Itch, peora of the Grepka, gcahir.s of tlie Latins. . 

" insect, the aouiis scabieL 

" baker's, brieklayer'a, grocer's, washerwoma 
AiJiurs 



PAOE 

1B6 



Kelis, Keloid ("ijy'} a tumor, and <ISos Jike), Others derive the 
words tcota xt^V " seabank or mole, or KjjXiq a Btaiu. Bj these 
terma are aigiiified a bjpprtrophotui growlb of the fibro-wUiilnr 
tissue of the skin. iSed aleo Cheloid 

Keloid of cicatrices 

Korion (Ktipuiv a honeycomb), a fortii of vegetable parasitic diHease 
allied to tinea tonsuraua. The follicles are iiiHamed ajid pour 
out a viBcid aecrt-tion 

Lentigo, Lexticula (^tou, hnlis, a lentil), a freckle; Ieatil-«haped 
niacultB ; they are not seasonal like suiiborn 

Leontiafits (X^wuwis liun-like), a term appUfd to the lion-like aspect 
of the face in tuln-i'ciilar lejHSJay. 

Lepra (XcVpa leprosy, from Kgnpat scaly). A term applied at one 
time to ti-ue leprosy, but now to the scaly disease Iepr& vnl- 
gai-is 123, j 



Iieprosy 

Leucasnius (Acwcot white), the sauie aa leucoderma, a whiteoitig of tb« 

■skill from defieieiicy of ])igment 

Leuce (AcuMK white), l"pra leucr, tlie white aniesthetic patch of true 

leprosy 

Leucoderraa 

Ltiucopatliia (Xcvko^ and *a8o% at!«ctiou), pigment deficiency. It 

generally is applied to albinisai 

Lichen {ktixrtv lichen, a time moss). The Greeks applied the plural 

lichenes to scaly diaeuscs. Lichen la now usetl to toffoSy ema of 

the papular diseases 

Lichen niber 

^' scrofujosua 

Liver-spot, a term applied to pigmeutury stains or to chloasma, 

which is B jiaraaitic disHase. 

Linear atrophy 

Lotions, lee FoHMUUUiy. 

Lupus (Latin for a wolf), so called from the ulcerating or devouring 

character of the disease. It ia regaideil its a licrofulous infloi 

uwtion and ulceration 



Hkcvuk [vuicida a stain), a 

mentary 

Uaoulffi aypliiliticn 



discoloration of the skin, mostly pig- 



GLOSSARIAL INDEX. 307 

PAGE 

Madura foot, a synonjTn for fungus foot of India, common at Madura, 228 

Malignant pustule 106 

Medicinal rashes \ ^ 62 

*' " silver discoloration 62 

" " arsenic 62 

" " copaiba •. 63 

" '' iodine 63 

" *' belladonna 63 

" " sulphur 63 

Mercurial remedies, see Formulary. 

Melanoderma (/icAa^, fitkoLyo^ black, 8cp/i.a skin), black discoloration, 245 

Melanopathia, same as the last, black disease 245 

Melas (fi€\as black), the term applied to the black anaesthetic patch 

in true leprosy — L e., lepra melas. 
Melasma (fickaa-fia a black spot), the same meaning as melanoderma, 245 
Meliceris (/icAt honey, mjpo': wax) the same as kerion. 
Metilagra (ay pa seizure) honey-like eruption, or eczema impetiginodea 

in some of its aspects. 
Mentagi-a (mentum chin, aypa seizure), a term applied to sycosis. . . 223 
Mentagrophyton {<f>vT6v a plant), parasitic sycosis, see Mentagra. . . 224 

Mercury in syphilis •. 154 

Mercurial formula*, see Formulae. 

Microsporon (/iixpo^ little, oTropo? a seed), a generic term for certain 
vegetable parasitic fungi found in chloasma and alopecia areata. 

Microsporon Audouini, the fungus of tinea decalvans 224 

** furfur, the fungus of chloasma 227 

Miliaria (inUium a millet seed) 250 

Miliary fever, an eruption of spots the size of millet seeds, due to 
vesicles produced as the result of excessive perspiration. JSttda- 

mina is the same disease 250 

Molluscum (inoUv^cuSy mollis, soft), small soft tumors produced by 
distention of the sebaceous glands by secretion. The resem- 
blance to molluscous animals is stated to have suggested the ap- 
plication of the term 256 

Molluscum contagiosum 260 

Morbilli (morbUlus distemper), measles. 

Mineral waters in skin diseases 295 

Morj^licea (iJLop<f>r) form), special diseases of the skin, in which a sub- 
stance like hard wax is formed in the skin 171 

Morve, a synonym of glanders. 

Mycosis (fxvKTj'; a fungus), a synonym of fi*amboesia or yaws ; so used 
by Alibert. 

Mycetoma, the fungus foot of India 228 

Myrmecia (fivpfXTji an ant), warts on the palms of the hand, or soles 
of- the feet. 



» 



N.evi;B, R mark ; they nre haiiy, 1^87 ; vuaeulap, 2S7 ; or jii^ciitArj', 

Nails, disenaee of. 230 

" pai-asitic 230 

NtsipliLsnut (vitK new, irXdur/ia formation), k new furniftlion. 

Ngerengere, the leprosy of New Zealand 164 

NenroBis, nerve flisonler ; 233 

NigritieH, Kigredo {niffer bluclc), darkness of the skin. 

Noli me tangere (toiicli me not), lupua exedens. 

Nomn (vo/tij, from rt/wii to spread), a general term for sloughing ulctra. 

Norwegian scabies 

Koaophyta (two^ disease, ifeirrov a plant), vegetable pai-aai tic diseases, 

Oi:('CpATios and diseuao 

(Estnis 

Ointments, gte FoHMCi^nr. 

Onychia (Swi tlic nail), inflammaiian of the nail 

Onychoiuy Posts {Smi a nuil, ii.vmp a fungus), paiitsitic disease of th« 

Opliiusis (u^i'tuTK, fi-om 5^5 a Boria'nt), aeqteutine. A l>ald place, in 

iri-egulnv band-like form. 
Osmidrosis lia/ii) odor, ahd tj^wwif sweating), fwtid perspiration , . . . 249 



* (ini;^'t thick, ^fia skin), a thickened state of skin. 
I'achydonuatocele (Pachydermia, which Heo, and n/kfi tnmor), hy- 

jjertrophy of the skin forming a tvimor 184 

Pachylosis (rax''^ tluckisli), the same as |>RcLydenuia. 

Papula (a jilmple), a solid elevation of the ekin of minute size S 

Papula. BiagnoMtic features of different pa]>ulte 8 

Papular diseast^B 145 

Pai-Uiiitii' diauases, uatura of 190 

" aiiimal 191 

" vegetable 3 U, 207 

Parasites («w Flistii) 208 

I'aratrinima (imfWTjH^iu to nib together), intertrigo 45 

Paixiuychia (impii about, ui^ the nail), 

whitlow 830 

" Byphiliiic 1S8 

Pathology, general remarks on 5 

Pediuulus, llie louse 195 

body IM 

pubis 19« 

head 1»9 

Pellagra (Italian, pdle skui, affrn I'ough), Italian leprosy 58 

Pemphigus [Tt/t^ a bladder or blister), one of the bullous diseaaes, US 




OLOBHAEUL DTOItX. 



sod 



^■^ FAOB 

TemphigtiB, sypbilitic 119 

Femio (nr^"^ tbe heel), a cLilblain. 

Pei-spimtion, alteration of 248 

Petechia {pHecUU, Italian, a flea-bite), iimiut« points of tjxtrava- 

sated blood seen iu piirjmra 243 

PhlycttniiA (^uKToini a vesicle), a general term for vesiculto and 

bladders. 
PhlyctwnosiB, an eruption of ]ihlycteme. 
Phlyz8«ion {^XuJaKtov, ^Xu'Cui to be hot), a jjustule with a hard and 

► iufliimed base witli a vivid red color, and aucteeded by a Lard, 
dark, thick scab, 
thsiriasia (^(i/wuri;, &om ^6iip a louse), the loiiaj disease, or 
morbuH pediciilaris 195, 23T 

Phytna {^vfia a tumor, or ^u'tu to spring forth), a eimall'boil. 

Phytoderma (^vtoir a plant, hipfia skin), any vegetable parasita that 
grows on the skin, hence phytodermata, llie disiMSW in which 
fungi occur 207 

Piaii (a raspberry), the same as irambcesiia 42 

Pigment alterations 244 

Pityriasis (irirtpov bran), a branny or scaly diseaae 166 

" pilaris 167 

Plastic inflammation ....'. 79 

Plica polouica (jAico to knit togetiier), the Polish plait, a disease aetm 

in Poland esjtecially, in which the hair is much matted together, 230 

Podelkonta, a nynouym for tlie fungus foot of India 228 

Pomplii, wheals, see next. 

Poinpholyx (tro/i^ciXu; a water bubble), the same disease as pemphigus. 

Ponigo, a tei-m applied to so many different diseases that it should 
be at once discarded to avoid endless confusion. 

Porrigo scutulata, an old term for tinea tonsurans. 

Prurigo and Pruritna {pntno to itcli). Tlie first is a particularly 

itcby and mshy disease; the second tlie sensation of itching. , . 234 

Psora {\inopa. the itch), scabies. Tlie Ureeks use the term to eczema. 

Fsoriiuiis, literally an itchy disease. Some apply the term to lepi'a 

vulgaris ; Mr. Wilson to the scaly slage of chronic eczema. . . 123, 129 

Psydracitt(i^8paKu)i', ^TJ^mJa blister on the tongue tip, from i/tSjwii' 
to lie, or linixpa vSpoKta cold blisters). An inflammatory pus- 
tule, less deep and red than phlyzaolous pustules. 

Pterygium {irripiii a ""ii'gt untpiii a nail), epidermis growing over the 

Pules irritans 101 

" penetrans 192 

Purpura (pvrpvreut pur[>le), the purple eruption caused by haemor- 

krhage into the akin 242 



FiiEtula or Pustule, an elevation of Bkin produced by a collection of [i 

Pustular Piaesaes 

Pyogenic {irvov pus, yiwurti creation), pns-pro«tucing. 



I 

I^ADKaevE. This, according to Boeck, is a bad form of eyplulis. ^^^^H 

Hhagades [payat a rent or clunk), a scab, fissure, or chap. ^^^^^H 

RhinoBcleroma, from 'Pis (genitive fia^) tlie nose, an<J SitXijpos hard, iT^^l 
Rodent ulcer {rtylo to gnaw), a. chronic ulcemting diEease, of the 

nature of fibroid degeneration, with subsequent ulceration .29, 13S 

Bosalia {roaa a rose), rose rasli, an ally of Hcarlutiua 53 

Boseola (i-osetw rose-colored), an acute febrile iliseBBe, acconipanied 

by the development of a raah of rosy hue , , 50 

Iloseola syphilitica 1{3 

Rotheln, a German term for rubella, or false measlcR H 

Kubella, A name given to a baatard form of measles by Dr. Veale. . , 42 

Rubeola {ruber red), measles 35 

Rupia (pinros <lirt), a syphilitic cmstijig diaoase \\7 

SxKCOPTEs, a synonym of the acanis acabiei J98 

Sarcocele 181 

Satyriasis (Sarvpot a satyr), a synonym of clepbantiafiis, from Uie 

fact that the countenance presents the aspect of a S^tyr. 
Sanroderma (travfios a Satuian reptile, Zipfia. sktn), ichtliyons Id 

wliich the plates or scales are like the out«r covering of the 

Saurian reptilea. 

Scabies {iraber« to scratch), the itch 

" Norvegica 

Scabitioa [scaher rough), tliiunesa of the nails. 

Scales ■ 

Scall {Kcala a scale), a term very variously applied ; it has no precise 

signification nowadays. 
Scarlatina {tcaAallo, Italian, a red-colored doth). Scarlet fever, . . . 
Sderoderma ({TxXijpoi bard, S<p/ia skin) a disease in whicb the skin 

hardens and indurate* 

Scleronia and Scleriasis. The same as the last 

Scratching, effect of 

Bcrofuioderma, explains itself as scrofulous disease of the skin 

Sebaceous cysts 

Seborrli<i;a {tnhum or aetnim suet, and ^'u to flow) sebaceous flux. 

Sex, influence of, on disease 

Shingles (eingidtem a girdle), herpes zoster 

Bibbens (from siwin, Celtic for i-aepbeny, or siwcna, wild rash), 

frambtEsiA, 



0L0S8AEIAL INDEX. 311 

PAGE 

)aps, see Formulary. 

mrgosis (oTrapyoo-is swelling). The same disease as bucnemia tro- 
pica 180 

)edalsklied, a Norwegian term for true leprosy or elephantiasis 
Grajcorum. 

)ilus (oTTi'yo? a spot), a mole or pigmentary nsevns. 

juama^ 11 

juamous Diseases, syphilide. 

tearrhoia {a-Tsap fat, pint to flow) the same as seborrhoea, excessive 

sebaceous secretion '. ; 252 

eatoma (orcop fat) a fatty tumor 255 

eatozoon (fwov animal), the animalcule found in the sebaceous 

ducts 255 

imulant remedies, see Formulae. 

;rophulus (arpof^s a twisted band), ordinarily described as the 

lichen of children. It is the " red gum," ** red gown " 87, 90 

:rumou8 diseases 130 

ty (stihan, Saxon, springing-up), a small boil, formed by one of the 

suppurating Meibomian glands of the eyelids 101 

Lidamina (sudo, to sweat) a vesicular eruption, the result of exces- 
sive sweating, the same as miliaria 250 

ulpliur rash. 63 

ip])uratiiig inflammation .• 91 

^xosis ((ruKoxTt? fig-like, from (tvkov a fig) inflammation of the seba- 
ceous follicles of the beard 223 

^^philodermata ((ri<^Ao9 defect, Scp/ia skin), syphilitic skin eruptions, 142 

y^philitic acne 148 

" lepra 145 

" lichen 145 

*' macular 144 

" onychia 153 

'* pemphigus 147 

" roseola 145 

" tubercles 151 

" ulcers 152 



• 



ELEANGEiECTASis (rcActos Complete, ctyyctov a vessel, ocrcuris exten- 
sion), tumor formed by an excessive growth of vessels. 

■jmperament, effect of 25 

^rminthus (rippLwOo^ or rcpc^iv^os, the turpentine tree), a carbuncle 
in shape and size like the ripe core of the turpentine tree. 

etter, of imcertain application, analogous to the word dartre. 

herapeutics, general remarks on 30 



ni), the generic term for vegetable para- 



Tiiiea (a motli or ■ 

sitic iliaeaaea. S18 

Tinea favosa 214 

" " its fungus 216 

" tonauraoB 216 

" " its fiingua 216 

" circinatA 220 

" sycoaia 223 

" « ito fungus. 234 

*' decalvans .• 224 

" " its fungus 226 

" versicolor 227 

" " its fmigiis 227 

" kerioii 218 

Trichogenoua {OpiS the hair, yiwaio to generate), hair-producing. 

Trichomyoes (6pi£, ''■p'X"! hair, fiu'tnjs a fiiugus), amy parasite of lliu 

Tiicliinosis (vmtw dieoase), disease of the hair. 
TricLophyt-on (^vrov a plant), a Tegetabli? paruaite of the hair. 

" tonatiranB 

Tubercula (tuber a swelling) the plural of tuberculum, dguifyiitg 
small swellukg. Tubercula ia applieil to the group of 
including cancer, lupus, fibroma, which commence by snmll 

durations 12 

Tubercula guiumata 153 

Tubercular leprosy 1S7 

" syphilids 161 

Tylosis (tuXukti!, tvKo9, ft knot), oallua callosity 36 

Tj-phoid fever, eruptions in 35 

Tj-phus " " 35 



1 



Urticaiiia (ucii 



I nettle), nettle-raah. , 



63 



Vaccisia {vneea a cow) cowpox 34 

Varicella (varicula, diro. of vams, a pimple), cLicken-pox 34 

Varus (nnevHn), a rash on the &c*, esjicciaJly acne. 

Vascular supply, alteration of. 1 86 

Veastils, bliHHl, alteration of 186 

Verruca, a wart 1 70 

" necrogenica 170 

Vesiculn (vesica, a bladder), flmall bla<lders, a Tesicle 8 

Veaiculaj diaeaae , 64 

" syphilis 146 

Vibices (vibex, a wheal) large petachin. 



GL086AUIAL INDEX. 31 *> 

PAGE 

Vitiligo (vitium, a blemish, or vitulus, a calf). The term is used 
very differently, some meaning thereby leucoderma, others the 
white scars left after ulcerative disease. 

Vitiligoidea (vitiligo, liSos), a general term, meant to designate a 
yellow discoloration under the eyelids, see Xanthelasma. 

Wheals, nature of. 55 

Xanthelasma (fav^o? yellow, fkcuriiXL lamina) yellow hypertrophy 
of the epithelial lining of the sebaceous ducts in the under eye- 
lid 253 

Xanthoderma, yellow skin 246 

Xeroderma {(rjpo^ dry, Scp/ua) a disease characterized by dryness and 

scaliness of the skin 187 

Yaws (a raspberry, Afric), framboesia 42 

ZiTTMAN treatment 155 

Zona (fcovi;, a belt), herpes zoster 113 

Zoster ({(ixTT^p a belt), herpes zoster, shingles 113 

Zymotic (C^fti;, leaven), acute contagious diseases, supposed to be due 
to the action of animal ferments or viruses. 



THE END. 



■ 



V